The purpose of this form is to determine whether you may be eligible for an exception. The statement must include the student's date of birth and the date of each immunization.VACCINATION EXEMPTION PURSUANT TO INDIANA CODE §20-34-3-2. The template allows employees to request an exemption from an employee vaccination mandate and provide corroborating information and documentation. This form allows employees to request an exemption to the COVID19 vaccination requirement on the basis of a religious belief. How do I apply for a religious exemption from immunizations? We want to make sure you have the most up to date information possible.