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___________________________________________