Immunization Exemption Form printable pdf download

Immunization Exemption Form

(School name or letterhead)

IMMUNIZATION EXEMPTION FORM

As a parent/guardian of

_______________________________________

(Student name)

in grade _______________ and date of birth _______________________,

I am requesting a waiver for the following immunizations:

All required immunizations:

Specific immunizations:

DTAP

I/OPV

MMR

Varicella

I understand that in the case of an outbreak of the specific disease for which my

child is not protected, my child will be kept out of school and school activities.

The length of time my child will be kept out of school may vary from a week to

over a month depending on the disease and length of the outbreak. I also

understand that if my child is kept out of school, the school is not required to

provide off-site classes or tutoring. The school may make reasonable

accommodations to assist my child in keeping up with classwork.

I am requesting a waiver for:

Sincere Religious Belief

Philosophical Reason

My explanation is as follows:

________________________________________________________________

Signed by: ______________________________________________

Relationship to student: ___________________________________

Date: __________________________________________________

Immunization Exemption Form