Religious Exemption Letter Template printable pdf download

Religious Exemption Letter Template

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

Religious Exemption Letter Template