Religious Exemption

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ANTIGUA AND BARBUDA
PUBLIC HEALTH ACT (DANGEROUS INFECTIOUS DISEASE) (AMENDMENT)
(NO. 17) REGULATIONS 2021
STATUTORY INSTRUMENT
2021, NO. 90

 

FORM IV

(Regulation 5A para. 5A(1) and (4), para. 8 and para. 20)

 

GOVERNMENT OF ANTIGUA AND BARBUDA
(Office of Ecclesiastical Commission)

REQUEST FOR RELIGIOUS EXEMPTION FROM COVID-19 VACCINATION

This form is for your use in applying for a religious exemption from the legal requirement under the Public Health Act (Dangerous Infectious Disease) (Amendment) (No. 16) Regulations 2021 that you be vaccinated against COVID-19. A religious exemption is granted on the basis of a sincerely held religious belief as professed and taught by the body or religious organization or group with which you are affiliated and not on the basis of your personal, political, scientific or sociological objection to the COVID-19 vaccine.

All parts of this form must be completed and the Declaration must be signed by you.

The Ecclesiastical Commission reserves the right to request further information from you before making a decision on your request. If further information is requested, it must be provided within the time specified or your request will be regarded as incomplete. Incomplete requests will not be considered.

The completed request form is to be sent to the Office of the Ecclesiastical Commission which is located at the Ministry of Social Transformation, Human Resource Development, Gender & Youth Affairs, John Henry Building, Popeshead & Dickerson Bay Streets, St. John’s, Antigua

Note: You are not permitted to work, or if a student, to attend face to face classes, until you have received a response to your request. Approval is not guaranteed. If you are granted a religious exemption you are required to provide a negative test for COVID-19 once in every 14-day period beginning on the 1st day of October, 2021 and to comply with such other preventive measures as may be imposed by the Board.

PART 1: OBSERVANT INFORMATION AND CERTIFICATION

Name of Observant: …………………………………………………………………………….

Age: ………. Date of Birth: ……………………………

Contact detail of Observant: ………………………………………………………………

Place of Employment/ School Attending (if applicable):

………………………………………………………………………………………………………

Address of Employer/School: …………………………………………………………….

I am a practising member of (Name of Religious Organization/Body or Group):

…………………………………………………………………………………………………………….

Name of Religious Leader and Title: ………………………………………………………….
Contact details of Religious Organization/Body/Group:

Email address: …………..………………………….. Telephone No: ………………..………

Initials are required next to each declaration

☐ I request exemption from the COVID-19 immunization requirements due to my sincerely held religious beliefs. I          understand and assume the risks of nonimmunization. I accept full responsibility for my health, thus removing            liability from the government of Antigua and Barbuda to the required immunization.

☐ I understand that as I am not vaccinated, in order to protect my own health and the health of the community, I            will comply with assigned COVID-19 testing requirements and other preventive measures including the wearing          of masks, physical distancing/social distancing and frequent sanitization.

☐ Should I be granted an exemption and I contract COVID-19 I will immediately report it to the health authorities          and comply with all isolation and quarantine procedures specified by the Ministry of Health Wellness and the              Environment.

I certify that the information I have provided in connection with this request is accurate and complete. I understand this exception may be revoked and I may be subject to disciplinary action if any of the information I provided in support of this exemption is false.

………………………………………………                                                                  …………………………………………
Name of Observant                                                                                              Name of Parent/Legal Guardian
                                                                                                                                       (if applicable)

……………………………………………………………….
Signature of Observant/Parent/Legal Guardian

………………………………………………
Date

PART 2. OBSERVANT PERSONAL STATEMENT

Name of Observant: ……………………………………………………………………………………………………

Please give a written statement of the nature of your sincerely held religious belief. Your statement should include the following:

1. A description of your sincerely held religious belief;
2. How long have you held this belief;
3. What is the source of your belief;
4. Are you opposed to all immunisation or only to the COVID-19 vaccine; and if only the
COVID-19 vaccine;
5. Why does your belief prohibit you from taking the COVID-19 vaccine specifically;
6. How long have you been a member of the particular religious organization/body/group;
7. Any other information that you want the Commission to consider as part of your request.

Please add the following certification at the end of your statement

I hereby sincerely declare and affirm that the foregoing statement that I have made in support of my request for a religious exemption are true and correct and I further acknowledge that if I have knowingly made or given any false or misleading information in this my personal statement I can be prosecuted.

……………………………………………………………….                                                …………………………………..
Signature of Observant/Parent or Guardian                                                      Date

PART 3. For the Leader of the religious organisation/Body/Group

(The Statement required to be given below is to be given by the Leader of the religious
organization/body or group)

Name of Observant: …………………………………………………………………………………………

Name and address of Religious Organization/Body/Group

………………………………………………………………………………………………………………………

 

RELIGIOUS ORGANISATION/BODY/GROUP STATEMENT

Please provide a written and signed statement supporting the basis of the observant’s sincerely
held religious belief. Your statement MUST include the following:
    1. How long has this Religious Organization/Body/Group been in existence;
2. Are you established – Registered as a Church/Religious Organisation/Friendly Society/Charity;
3. What are the tenets of the Religious Organisation/Group/Body;
4. Does the religious organization/body/group have a constitution; if so, please attach it to your statement;
5. Is the Organization oppose to all immunization/vaccination or only to the COVID-19 vaccination;
6. Is the objection to the COVID-19 vaccine based on any particular teaching of the Organisation/body/group              (please specify which belief);

Please add the following certification at the end of your statement

I certify that (name of Observant) is a member of my religious organization/body/group and has been for…………….. years.

I further certify that the statement that I have given is true and correct and I acknowledge that I
can be prosecuted if I have made or given any false statement with the intent of securing an
exemption for the Observant.

 

Name of Leader of Religious Organisation/Body/Group

Signature

Date

 

Made the 1st October 2021

 

 

Eustace Lake
Chairman of the Central Board of Health