COVID-19 Vaccine Mandate Inquiry Form

Please provide the following information if you are requesting legal guidance regarding how to request a religious exemption from a COVID-19 vaccine mandate.

Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Phone*
Name of the business or institution requiring COVID-19 Vaccine

Please indicate the name of the business or institution that is requiring COVID-19 vaccination and whether you are an employee, student or both.
Exemption form?
- Yes
- No
Has that business or institution provided you with a form to request exemption?
Please briefly describe why you wish to apply for a religious exemption from the vaccine mandate:
Date your exemption is due
Other relevant information
Please add any other information you believe is relevant to your request for religious exemption from the vaccine requirement
How did you hear about us?
I would like to receive email communications from the Independence Law Center / PA Family Institute
- Yes
- No