COVID-19 Non Medical Exemption Form - 22-23 School Year


Dancer Details

First Name:  
Middle Name:  
Last Name:  
Date of Birth:

Program

Parent/Guardian Details

Parent/Guardian First Name:  
Parent/Guardian Middle Name:  
Parent/Guardian Last Name:  

Relationship to Student:

Vaccine Required for School Entry
Check Vaccine Declined

Statement of Exemption

I am the student or parent/guardian (if student is under 18 years of age) of the above-named student and am declining the vaccine indicated above due to a religious belief whose teachings are opposed to immunization or a personal belief that is opposed to immunization with the COVID-19 vaccine. The information I have provided on this form is complete and accurate, and I acknowledge and understand the following:

  • I may change my mind at any time and accept vaccination(s) for my myself/child in the future.
  • Those who are not vaccinated have a significantly increased likelihood of becoming infected and/or ill after exposure to COVID-19.

Leave this empty:

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Signature Certificate
Document name: COVID-19 Non Medical Exemption Form - 22-23 School Year
lock iconUnique Document ID: 1646a8813c4135ec1abecfa7a0d6c6071507c132
Timestamp Audit
August 16, 2022 7:56 pm ESTCOVID-19 Non Medical Exemption Form - 22-23 School Year Uploaded by Gail D'Addario - support@joffreyballetschool.com IP 172.119.197.59
August 16, 2022 8:02 pm ESTNancy Cole - ncole@joffreyballetschool.com added by Gail D'Addario - support@joffreyballetschool.com as a CC'd Recipient Ip: 172.119.197.59
August 17, 2022 10:44 am ESTNancy Cole - ncole@joffreyballetschool.com added by Gail D'Addario - support@joffreyballetschool.com as a CC'd Recipient Ip: 172.119.197.59
November 21, 2022 10:22 am ESTNancy Cole - ncole@joffreyballetschool.com added by Gail D'Addario - support@joffreyballetschool.com as a CC'd Recipient Ip: 172.119.197.59
November 21, 2022 10:33 am ESTNancy Cole - ncole@joffreyballetschool.com added by Gail D'Addario - support@joffreyballetschool.com as a CC'd Recipient Ip: 172.119.197.59