School Immunization Religious Exemption Form
School Immunization Religious Exemption Form
Parent request for a religious exemption from school-required immunizations, including affirmation of sincerely held beliefs.
Student full name *
Your answer
Date of birth
School / district *
Your answer
Grade level
Vaccines for which exemption is requested
Religious affiliation (optional)
Your answer
Statement of sincerely held religious belief that conflicts with immunization
Your answer
I understand that during a vaccine-preventable disease outbreak, my child may be excluded from school for the duration of the outbreak.
+ 7 more questions
About this template
Parent request for a religious exemption from school-required immunizations, including affirmation of sincerely held beliefs.
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