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Figure 9 - Long Description

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.

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