Student Health Services Fee Waiver Request

A mandatory student health fee is charged each semester. The amount of the fee is determined by the state of California. You may hereby request exemption from the payments of a mandatory health fee for Student Health Centers or other health services provided in accordance with California Code of Regulations, Title 5, section 554702 and collected in accordance with California Education Code section 76355. Please see AP 5030.

To request this waiver, you must depend exclusively upon prayer for healing in accordance with the teachings of a bona fide religious sect, denomination, or organization, and request exemption from the payments of the fee for health supervision and services provided in California Education Code section 76355(c)(1) which reads as follows:

**(c) The governing board of district maintaining a community college shall adopt rules and regulations that exempt the following students from any fee required pursuant to subdivisions (a) which is the fee for health supervision and services, including direct or indirect medical and hospitalization services, or operation of Student Health Center or centers, or both:

(1) Students who depend exclusively upon prayer for healing in accordance with the teachings of a bona fide religious sect, denomination, or organization.

(2) Students who are attending a community college under an approved apprenticeship training program. (NOTE: The Student Health Fee is waived for IVC students who are in the Dual Enrollment, or Restorative Justice program.)

**If exemption (1) applies to you, it is mandatory that the Student Health Centers receive an original letter on Church Letterhead signed by the Minister/Pastor/Religious Leader explaining that you depend exclusively on prayer for healing. Therefore, please proceed with completing this form. NOTE: The letter must include your name and date of birth.

Once this letter has been received and verified, it will be sent for reviewal. If your request is approved, the fee will be waived.

This request must be submitted by the Census date of the semester/intersession you are requesting the waiver for.

**Note: Waiver is only valid for one semester.