Religious:If desired, attach a page with religious statement or a letter from your religious leader. â–¡ Good Cause: If desired, attach another page with reason(s).This REQUEST is in accordance with OHIO PURVIEW for EXEMPTION of GOOD CAUSE, INCLUDING RELIGIOUS CONVICTIONS. We've provided a request form template for you to download and fill out here. In either event, you can use this document as a general guide to help you think about and personalize your own request for a religious exemption. I understand that the immunization Law permits me to sign a waiver on my child taking the immunization. I respectfully submit this statement of faith for a Constitutionally recognized and protected religious exemption against a mandatory injection. I am requesting an exception from the COVID-19 vaccination on the basis of a sincerely held religious belief. Individual's name: Date of birth: Phone number:. You are not required to fill out or complete a specific form.