Request for Exception from COVID-19 Vaccination Requirement

I am requesting an exception to the requirement to show proof of vaccination before entering a building on the Kimmel Cultural Campus. I understand that, if granted this exception, I must still show at entry: (a) the exception approval letter; and (b) proof of a negative COVID-19 PCR test taken within 72 hours of entry. This form must be submitted no later than 10 days before desired entry date. Delayed submission or refusal to respond to follow-up inquiries may result in automatic denial or an inability to grant exception before the requested entry date.

I am requesting an exception for the following reason: *


The following is a detailed description of the basis for my exception request. If I have declined other vaccinations or medications on the same basis, I have detailed them below. Documentation from a healthcare provider or religious leader may also be provided with this form to support the request.

To submit an attestation from a medical provider or religious leader, please download and complete the Certification from Healthcare Provider or Religious Leader Form. Please be sure to have your medical provider or religious leader sign the form. Please scan the completed form and submit by email to [email protected].

By typing your name in the box provided, you agree to signing this document, indicating all information provided is accurate.

I verify that the information I am submitting to substantiate my request is true and complete. I understand that additional information or documentation may be required.

 

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, do not provide any genetic information when responding to this request for medical information. "Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, or genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.