Request for Exemption/Accommodation Related to COVID-19 Vaccine

The El Monte Union High School District ("District") is committed to complying with all laws protecting individuals with disabilities or medical conditions. When requested, the District will provide an
Exemption/Reasonable Accommodation for any known medical condition or disability of a qualified individual which prevents the students from receiving a COVID-19 vaccine, provided the requested accommodation is reasonable and does not create an undue hardship for the District or pose a direct threat to the health and safety of others in the school site and/or the requesting student.

Steps to request a Medical Exemption/Accommodation related to the District’s COVID-19 vaccination
policy:

1. Complete this informational form.
2. EMUHSD will email you the required documents that must be completed by a medical provider (M.D., D.O., PA-C, CNP).
3. Parent submits medical documentation to EMUHSD (Pupil Services).
4. Individual exemption/accommodation meeting scheduled with EMUHSD representative and family.
5. Final decision mailed and emailed to family.

This above listed documentation will be used by the District to engage in an interactive process to identify and determine eligibility for possible accommodations. If a family refuses to provide such documentation in good faith, the families refusal will impact the District’s ability to adequately understand the families request or effectively engage in the interactive process to identify possible accommodations.

Medical exemptions/accommodations for the COVID-19 vaccine will be considered if the parent provides a written certification by a licensed, treating medical provider [a physician (MD or DO), nurse practitioner (NP), or physician’s assistant (PA)], of one of the following:

1. The applicable CDC contraindication for the COVID-19 vaccine, or
2. The applicable contraindication found in the manufacturer’s package insert for the COVID-19 vaccine, or
3. A statement that the physical condition of the person or medical circumstances relating to the person are such that immunization is not considered safe, indicating the specific nature and probable duration of the
medical condition or circumstances that contraindicate immunization with the COVID-19 vaccine.
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Parent First and Last Name *
Parent Email Address *
Parent/Guardian Contact Number *
Parent Primary Language *
Student First Name *
Student Last Name *
Student ID Number *
Student Email Address *
Student School *
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