Student Vaccine/Booster Upload & Exemption Request

Submit the form after being fully vaccinated. Select your vaccine status and upload a picture of your vaccination card, or a screenshot from the state’s Digital COVID-19 Vaccine Record, which you can access here: https://myvaccinerecord.cdph.ca.gov/

If you have received your booster, please only submit the form once, and select boosted.

If you are requesting an exemption, please mark either medical exemption requested or religious exemption requested.

Student ID*

Student First Name*

Student Last Name*

Student Email*

Please use your Delta Mustangs Email Address

Student Date of Birth*

Vaccine Mandate Status*

Select

Dose #1 Manufacturer*

Select or enter value

Dose #1 Date*

Dose #2 Manufacturer

Select or enter value

Dose #2 Date

This is the date of your last dose. *Does not include booster date.

Booster Manufacturer

Select

Booster Date

Upload a copy of vaccine card*

Drag and drop files here or

Requesting Exemption from Booster Only

Check this box if you are requesting an exemption from the booster only

Medical Exemption Requested

I am medically unable to be administered a COVID-19 vaccine because of a personal medical condition.

Religious Exemption Requested

I have a strongly held religious belief, religious practice or religious observance that does not allow me to be administered vaccines, including the COVID-19 vaccine.

Not a Guarantee*

I understand, submitting this form is not a guarantee of approval. I understand the San Joaquin Delta Community College District will require additional verification which I will be notified of following this submission.

Electronically Approve*

Religious and Medical Exemptions may take up to 14 days to process and approve. If you have not received a compliance approval confirmation based on the San Joaquin Delta College Vaccination Mandate by the time of your registration, it is recommended that you sign up for online classes, in case your exemption is not approved. Once your exemption is approved, you may adjust your spring schedule to add face-to-face or hybrid courses, depending on class availability.

Testing Required*

I understand that if my exemption is approved, I am required to undergo COVID-19 testing twice a week on campus in order to comply with the District's vaccination/booster mandate

Send me a copy of my responses

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