NEW COVID-19 Vaccination Exception Request
Acceptable exceptions from the CADPH COVID-19 Vaccination Policy
NOTE: This form must be printed and signed, digital signatures will not be accepted.
You must have Adobe Reader on your computer to open and print the respite forms. Click here if you need to add this program.
To designate a respite worker, both parties must complete and sign/initial the areas indicated on the Parent/Guardian Waiver. The person being designated must complete a W-4 and DE 4. A copy of a signed Social Security card or other documentation matching the person’s name to the Social Security number should be included. The original forms must be received by Respite, Inc. before a worker can be paid, however, services can be provided during the interim. In order to match the forms with the correct person it is best to submit the original forms with the person’s first timesheet.
Click on the following titles to open and print forms:
Parent/Guardian Waiver – Designate a Respite Worker
Fill in blanks as indicated.
W-4 (Federal Withholdings)
A copy of documentation matching the respite worker’s name with Social Security number should be included.
DE 4 (California Withholdings)
This form is for designating California taxes.
I-9 Employment Eligibility
Keep this form for your records only. Do not return this form to our office.