Personal Details

First Name:  
Middle Name:  
Last Name:  
Date of Birth (mm/dd/yy):

Intensives

Vaccine Required for School Entry
Check Vaccine Declined

Statement of Exemption

I am declining the Covid-19 vaccination due to a religious belief whose teachings are opposed to immunization, a personal belief that is opposed to immunization with the COVID-19 vaccination shot or a medical reason that is deemed unsafe for me to have the COVID-19 vaccination. I understand that I have to follow all Joffrey Ballet School policies for non-vaccinated individuals, which includes extra testing if I am involved in a close contact situation. 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 myself in the future.
• Those who are not vaccinated have a significantly increased likelihood of becoming infected and/or ill after exposure to COVID-19. Close contacts who are unvaccinated have different isolation rules, according to CDC policy.