North Carolina Immunization Religious Exemption Form printable pdf download

North Carolina Immunization Religious Exemption Form

NORTH CAROLINA IMMUNIZATION LAW

RELIGIOUS EXEMPTION

NORTH CAROLINA GENERAL STATUTE 130A-157

SECTION 130A-157. Religious exemption. - If the bona fide religious beliefs of an adult or the parent,

guardian or person in loco parentis of a child are contrary to the immunization requirements contained in

this Part [Chapter 130A, Article 6, Part B], the adult or the child shall be exempt from the requirements.

Upon submission of a written statement of the bona fide religious beliefs and opposition to the

immunization requirements, the person may attend the college, university, school or facility without

presenting a certificate of immunization.

_______________

Pursuant to the aforementioned N.C.G.S. 130A-157, I, the undersigned, declare the immunization

requirements as set forth in N.C.G.S. 130A-152 contrary to my bona fide religious beliefs and claim, as

permitted by the law, an exemption from the immunization requirements of your institution for the

undersigned minor child under my legal care and guardianship.

NAME _________________________________________

SIGNATURE____________________________________

ADDRESS______________________________________

_______________________________________________

PHONE________________________________________

DATE__________________________________________

MINOR CHILD'S NAME _________________________________________

DATE OF BIRTH ______________________________________________

ADDRESS______________________________________

_______________________________________________

PHONE_________________________________________

DATE___________________________________________

North Carolina Immunization Religious Exemption Form