Girl Scouts Immunization Exemption Form printable pdf download

Immunization Exemption Form

What is the purpose of this form?

Because our camps have a potential for communicable diseases, we recommend that program participants are appropriately

immunized for, at minimum, the following diseases: tetanus, mumps, measles, rubella, polio, smallpox, pertussis (whooping

cough), and diphtheria. This being said, we recognize that some individuals may not be fully immunized for reasons that are

biophysical (e.g., the individual is allergic to a serum component) or of personal choice (e.g., faith belief). This form is intended

to capture information about individuals who are not fully immunized.

Who should complete this form?

• A custodial parent/legal guardian of an underage participant/camper who is not fully immunized.

• An adult participant, including a staff member, who is not fully immunized.

I request that ________________________________________, enrolled in session ______________ be exempted from the

Name of Individual

immunizations required for attendance at Girl Scouts of Northern California camps. The reason for this request is as follows:

_________________________________________________________________________________________________

To the best of my knowledge and belief, the person named above is and has been in normal good health and is free from all

communicable or contagious disease. Should this participant show symptoms that reasonably indicate the presence of a

communicable or contagious disease, I agree that a physical examination may be performed. I also agree that if any such

disease is found, we – the named individual and his/her family – will comply with the quarantine or isolation procedures

required of Girl Scouts of Northern California as directed by the state’s Department of Health. I understand the refund policy

for this camp.

It is further understood that, should a communicable disease emergency arise, I will be notified. However, in the event that I

cannot be contacted, the camp’s administrator(s) and healthcare staff may take the temporary measures they deem

necessary to protect the health status of this participant.

I release and forever discharge Girl Scouts of Northern California and each and every one of its officers, directors, employees,

agents, insurers, affiliates, attorneys, or any other person or persons associated with any or all of them or any variation in the

name of any or all of them who might be liable (the Released Parties) from all causes of action, suits, claims, demands, or any

other damages or costs associated with actions taken by the Released Parties relative to the health, sickness and treatment

_____________________________________________.

Name of Individual

I further understand and acknowledge that I make this release in full accord and satisfaction of and in compromise of any

current or future disputed or alleged claims or causes of action relative to the health, sickness and treatment of

_____________________________________________ against the Released Parties.

Name of Individual

I represent and acknowledge that I have read and understand this agreement and release and warrant that all statements

made herein are true to the best of my knowledge. I further warrant and acknowledge that I am of legal age, legally competent

to execute this agreement and release, and accept full responsibility therefore.

Signature

Signature of Parent/Guardian:

Signature

of Parent/Guardian:

Date:

__________________________

_______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________

Street Address

City

State

Phone Number

Girl Scouts Immunization Exemption Form

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