Examples
o f
P rovider
L etters
o f
E xemption
RELIGIOUS EXEMPTION:
To (whomever you need to address at whatever school),
In accordance with RCW 28A.210.090 Immunization program—Exemptions, and, as the licensed health
care practitioner for (child's name), I am submitting this written and signed certification that the
religious beliefs of the parent of (child’s name) are contrary to the required vaccinations, and that he/she
is exempt from all required vaccines. I have provided the parent with information about the benefits and
risks of vaccination to the child.
Sincerely,
(doctor's name, signature, and title)
(parent/legal guardian, signature)
date
PHILOSOPHICAL:
To (whomever you need to address at whatever school),
In accordance with RCW 28A.210.090 Immunization program—Exemptions, and, as the licensed health
care practitioner for (child's name), I am submitting this written and signed certification that the parent
has a philosophical objection to the vaccination of (child's name), and that he/she is exempt from all
required vaccines. I have provided the parent with information about the benefits and risks of
vaccination to the child.
Sincerely,
(doctor's name, signature, and title)
(parent/legal guardian, signature)
date
MEDICAL:
To (whomever you need to address at whatever school),
In accordance with RCW 28A.210.090 Immunization program—Exemptions, and, as the licensed health
care practitioner for (child's name), I am submitting this written and signed certification that the
vaccines required by rule of the state board of health are, in my judgment, not advisable for the (child's
name) and that he/she is permanently exempt from all required vaccines. I have provided the parent with
information about the benefits and risks of vaccination to the child.
Sincerely,
(doctor's name, signature, and title)
(parent/legal guardian, signature)
date