Health Services Center


Request for Religious Exemption to Immunization Law

A written statement is required for religious exemption requests.

A student must submit a written statement stating that they hold religious beliefs contrary to the practice of immunization in order to qualify for a religious exemption.  Students under 18 years old must submit such a statement signed by his/her parent(s) or guardian(s) to qualify for religious exemption.  This statement must demonstrate that the student, or his/her parent(s) or guardian(s) holds sincere and genuine religious beliefs which are contrary to the practice of immunization. Each statement requesting a religious exemption must be specific to Adelphi University.  Prior religious exemption statements addressed to other institutions are not considered valid.  Public Health Law Section 2165 does not allow for philosophical, political, scientific or sociological exemptions.  When a religious exemption is requested, Adelphi University may require supporting documentation.  You will be notified of the outcome of this request.

Please provide a written statement addressing all of the following elements:

  1. In your own words why you are requesting this religious exemption.
  2. Describe the religious principles that guide your objection to immunization.
  3. Indicate whether you are opposed to all immunizations, and if not, the religious basis that prohibits particular immunizations.

Assure that your name and ID # are clearly printed on the top of your letter.  Sign the bottom if you are over 18 years old; if younger than 18 please have your parents sign the letter.

Be aware that if there is a communicable disease outbreak involving the campus anyone holding a religious exemption may be withheld from attending class and co-curricular activities until such time that the Department of Health declares the campus free from disease.
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