Form Cre-1 - Certificate Of Religious Exemption - Commonwealth Of Virginia
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1COMMONWEALTH OF VIRGINIA
CERTIFICATE OF RELIGIOUS EXEMPTION
Name ____________________________________
Birth Date _______________________
Student I.D. Number __________________________________
The administration of immunizing agents conflicts with the above named
student's/my religious tenets or practices. I understand, that in the occurrence of an
outbreak, potential epidemic or epidemic of a vaccine-preventable disease in my/my
child's school, the State Health Commissioner may order my/my child's exclusion
from school, for my/my child's own protection, until the danger has passed.
_______________________________________________
___________________________
Signature of parent/guardian/student
Date
I hereby affirm that this affidavit was signed in my presence on
This ____________________________________________ Day of _____________________
Notary Public Seal
Form CRE-1; Rev. 00/92
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