Religious Exemption for Influenza Vaccination

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Please complete the Religious Exemption form if your strongly held religious beliefs prevent you from getting the flu vaccine.

Teammate Name:

If Atrium Health Employee Contact Telephone Number:

I am requesting a religious exemption from receiving the seasonal influenza vaccine. As described below, my strongly held relgious beliefs prevent me from receiving the seasonal influenze vaccine. Please Provide a statement regarding your request:

I do hereby affirm that the above inforamtion reflects my strongly held religious beliefs and is true, accurange and complete.

I affirm the above information

I do not affirm the above information

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Religious Exemption for Influenza Vaccination

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