JLCB-E

NSBA Code: JLCB-E

IMMUNIZATION EXEMPTION FORM

As the parent/guardian of _______________________ in grade _______, and with the date of birth of ______________, I am requesting a waiver for the following immunizations:

___ All required immunizations

___ DTaP (Diphtheria, Tetanus, and Pertussis)

___ I/OPV (Polio)

___ MMR (Measles, Mumps, & Rubella)

___ Varicella (chicken pox)

I understand that in case of an outbreak of the specific disease for which my child is not protected, my child will be kept out of school and school activities. The length of time that my child will be kept out of school may vary from a week to over a month depending on the disease and length of the outbreak. I also understand that if my child is out of school, the school is not required to provide off-site classes or tutoring. The school may make reasonable accommodations to assist my child in keeping up with classwork.

I am requesting the waiver for:

___ Sincere religious belief

___ Philosophical reasons

My explanation is as follows:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signed by:____________________________

Relationship to student:__________________

Date:________________