Qualtrics Form | UC Religious Exception Request Form

This form should be used by University of California students to request an EXCEPTION based on a Religious Objection to any of the mandatory vaccinations required by the Policy on Vaccination Programs and the Vaccination Program Attachments. Those who are permitted by University Policy and applicable public health directives to decline a vaccination (such as an influenza vaccination) should use the application Vaccination Declination Form instead.

Student Name (print):

Date of Birth (DOB):

Student ID#:

Student Email: