Health Fee Waiver Form

HEALTH FEE WAIVER FORM

In accordance with California Education Code Section 76355, Title 5, sections 54700-54710, and San Joaquin Delta College Board Policy 5030, you may waive the health fee for the following reasons:

Students who depend exclusively upon prayer for healing in accordance with the teachings of a bona fide religious sect, denomination, or organization. (i.e., do not believe in the use of doctors, medicines, surgeries, or other medical treatments). Note: A belief in the power of prayer for healing, or the use of prayer as part of healing practice, in addition to other medical interventions, does not qualify a student for this exemption.

Students who are attending a community college under an approved apprenticeship training program.

If you are eligible for an exemption, please fill out this form, specify your reason for exemption, and provide the required documentation.

I hereby request to waive the Health Fee for student health services provided by San Joaquin Delta College by declaring that I meet the specified exemption criteria: *

PLEASE REVIEW PRIOR TO SUBMITTING YOUR REQUEST

Supporting documentation required- Supporting documents may include a letter written and signed by a pastor or senior religious leader on official letterhead confirming your membership in the organization and that your religion rejects all forms of medical intervention.
Health Fee Waiver form must be submitted prior to the start of each semester- Waivers do not carry over across semesters. Refer to the refund policy related to enrollment fees for details.
Review and Processing- Requests for exemptions are directed to the Associate Vice President of Student Services for initial review before processing. You will receive an email confirmation after your request has been reviewed and processed. Please allow 5 business days for processing.

Student Name*

First NameLast Name

Student ID #*

Email*

eg. janesmith123@mustangs.deltacollege.edu

Signature*

Date*

Acknowledge and Submit*

I have attached all required supporting documents.I certify under penalty of perjury, that the foregoing statements are true and correct.

Supporting Documentation*

For inquiries concerning the health fee, the health fee waiver form, and student health services provided at San Joaquin Delta College, please refer to the Student Health & Wellness Resources website or contact (209) 954-5151 ext. 6182.