Certificate of Exemption—Personal/Religious
NOTICE: A parent or guardian may exempt their child from the vaccinations listed below by submitting this completed form to the child’s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. An exempted child/student may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. Vaccine-preventable diseases still exist, and can spread quickly in school and child care settings. Immunization is one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death.
PERSONAL/PHILOSOPHICAL EXEMPTION* Diphtheria Hepatitis B Hib Pneumococcal Polio Pertussis (whooping cough) Tetanus Varicella (chickenpox) *Measles, mumps, or rubella may not be exempted for personal/philosophical reasons per state law
Personal/Philosophical or Religious Exemption I am exempting my child from the requirement my child be vaccinated against the following disease(s) to attend school or child care. (Select an exemption type and the vaccinations you wish to exempt your child from):
Parent
NOTICE: A parent or guardian may exempt their child from the vaccinations listed below by submitting this completed form to the child’s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. An exempted child/student may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. Vaccine-preventable diseases still exist, and can spread quickly in school and child care settings. Immunization is one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death.
PERSONAL/PHILOSOPHICAL EXEMPTION* Diphtheria Hepatitis B Hib Pneumococcal Polio Pertussis (whooping cough) Tetanus Varicella (chickenpox) *Measles, mumps, or rubella may not be exempted for personal/philosophical reasons per state law
Personal/Philosophical or Religious Exemption I am exempting my child from the requirement my child be vaccinated against the following disease(s) to attend school or child care. (Select an exemption type and the vaccinations you wish to exempt your child from):
Parent