Immunization Exemption Form printable pdf download

Immunization Exemption Form

SCARBOROUGH SCHOOL DEPARTMENT

P. O. BOX 370

SCARBORUGH, ME 04074

SCHOOL: _________________________

IMMUNIZATION EXEMPTION FORM

As a parent/guardian of ______________________________ in grade_________,

and date of birth: _____________________, I am requesting a waiver for the following

immunizations:

All required immunizations:

Specific immunizations:

DTP

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 class

work.

I am requesting a waiver for (choose one):

Serious Religious Belief

Philosophical Reason

Medical Reasons (must have explanation documented by physician)

My explanation is as follows:

_____________________________________________________________________

Signed by: ___________________________________________________________

Relationship to student: _________________________________________________

Date: _________________________

PLEASE NOTE EXEMPTIONS MUST BE RENEWED AT THE START OF

EACH SCHOOL YEAR.

Immunization Exemption Form