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Figure 9 shows a form for a Statement of Exemption to Immunization Law. The text follows:
Date of Birth
Statement of Exemption to Immunization Law
In the event of an outbreak, exempted persons will be subject to exclusion from school and quarantine.
Medical Exemption: The physical condition of the above named person is such that immunization would endanger life or health, or is medically contraindicated due to other medical conditions.
Signed (Physician):
Date:
Religious Exemption: Parent or guardian of the above named person or the person himself/herself adheres to a religious belief opposed to immunizations.
Signed: (Parent, guardian, emancipated student/consenting minor)
Date:
Personal Exemption: Parent or guardian of the above named person himself/herself adheres to a personal belief opposed to immunizations.
