Immunization Exemption Form printable pdf download

Immunization Exemption Form

IMMUNIZATION EXEMPTION FORM

As a parent/guardian of ____________________________________________, I am requesting a waiver

Child’s name

for the following required immunizations:

All required Immunizations

DTAP (Diphtheria, Tetanus and Pertussis)

IPV/ OPV (Polio)

MMR

Varicella (Chicken Pox)

HIB (Haemophilus influenzae type B)

Hepatitis A

Hepatitis B

PCV 7 (Pneumococcal Conjugate)

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 the program and program activities. The length of time my child will be kept out of

the program may vary from a week to over a month depending on the disease and length of the outbreak.

I am requesting this waiver because of:

My sincere religious belief

Philosophical reasons

Medical Reasons (I have attached the required MD verification.)

My explanation is as follows: __________________________________________________________________

__________________________________________________________________________________________________

_________________________________________________________________________________________________

__________________________________________________

___________

Signature

Date

__________________________________________________

Relationship to student, if not a parent

5 Stephenson Lane, Belfast, Maine 04915 telephone 207-338-2200

Immunization Exemption Form