Request for Exemption COVID-19 Vaccination Requirement

Request for Exemption
COVID-19 Vaccination Requirement

The Funders Network (TFN) is committed to protecting the health and safety of our staff, consultants, members and program participants. To create as safe of an environment as possible for those attending our events, we are requiring, among other things, proof of COVID-19 vaccinations and negative Covid-19 testing. You may find more information about TFN’s health and safety protocols on the website.

A medical exemption from COVID-19 vaccination is allowed for certain recognized contraindications.

If you have an allergy to the COVID-19 vaccine or a specific medical condition that precludes the COVID-19 vaccination requirement, you may submit this form to seek a medical exemption from TFN’s COVID-19 vaccination requirements for TFN events.

If your religious beliefs or practices conflict with The Funders Network’s COVID-19 vaccination requirements, you may submit this form for review by TFN Staff.

I request an exemption from TFN’s COVID-19 vaccination requirements for one or more of the following reasons:

Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccineImmediate allergic reaction of any severity to a previous dose or known (diagnosed) allergy to a component of the vaccine (Vaccine Ingredients)Other Medical ReasonReligious Reason

Other Medical Reason: Please provide this information in a separate narrative that describes the other medical reason justifying an exemption in detail.

Religious Reason: Please explain why you are seeking a religious exemption, the religious principles that guide your objection to immunization, and please indicate whether you are opposed to all immunizations, and if not, the religious basis on which you object to COVID-19 immunizations.

Affirmation

I knowingly affirm and certify that the information that I have provided in support of my request for a waiver from TFN’s COVID-19 vaccination requirements is true and correct and any intentional misrepresentation may result in legal action.

First Name

Middle Name

Last Name

Suffix

Email Address

Phone Number

Organization Name

Summary of Next Steps

For privacy, you will not receive an automated email confirmation of this form submission.
This request will be manually reviewed and acknowledged by designated TFN Staff. Additional information may be requested.
After review, you will be notified of the decision regarding your requested exemption.
If granted an exemption, you will be required to undergo COVID-19 testing in addition to observing all COVID-19 health and safety protocols.
TFN will reconsider a denial only if you bring forth new information supporting your request. For reconsideration of a denial, please contact Maureen Lawless, vice-president and director of Member Services, maureen@fundersnetwork.org

Contact Information