Exemption to Immunization

Name ________________________________________ Birthdate ________________________

Address ______________________________________ Parent/Guardian ____________________

_____________________________________________ Telephone _______________________

Please Circle Present Grade:    K    1    2    3   4    5    6    7    8    9    10    11    12      Sp. Ed.

STATEMENT OF EXEMPTION TO IMMUNIZATION LAW

MEDICAL EXEMPTION

The physical condition of the above named child is such that immunization would endanger life or health.

Signed _________________________________________________ Date __________________

                                   (Physician)

RELIGIOUS EXEMPTION

(Includes a strong moral or ethical conviction similar to a religious belief.)

Parent or guardian of the above named child adheres to a religious belief whose teachings are opposed to such immunizations.

State your reason for requesting a religious exemption _____________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Signed __________________________________________________ Date _________________

                                                         (Parent or Guardian)