State Of Idaho Certificate Of Exemption Child Care Immunization Requirement
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2State of Idaho
CERTIFICATE OF EXEMPTION
Child Care Immunization Requirement
Child’s Name______________________________________________________________ Child’s Birth date ____________________
I________________________________________, as the parent or guardian of ___________________________________________,
Parent/Guardian Name
Childs Name
A. CHECK THE BOX(ES) FOR WHICH AN EXEMPTION IS BEING CLAIMED
DTaP
Polio
Measles
Mumps
Rubella
Hepatitis B
Hib
In the event of a disease outbreak your child may be excluded from Day Care. The period of exclusion may be for a few days
up to several months and may extend to two incubation periods after the last case depending upon the disease and the
number of cases.
Please read the following statements and initial each statement regarding vaccine preventable diseases for which an
exemption is being claimed.
Diphtheria: I understand by not receiving the Diphtheria vaccine, my child is at risk of developing a sore throat, low-grade fever, heart
complications, paralysis, respiratory complications, coma and even death.
__________
_______________
Initial
Date
Tetanus: I understand by not receiving the Tetanus vaccine, my child is at risk of developing seizures and possible fatal neuromuscular
disease.
__________
_______________
Initial
Date
Pertussis (Whooping Cough): I understand by not receiving the Pertussis vaccine, my child is at risk of developing pneumonia,
seizures, inflammation of the brain, neurological complications and even death.
__________
_______________
Initial
Date
Polio: I understand by not receiving the Polio vaccine, my child is at risk of developing a fever, sore throat, nausea, headaches,
stomachaches, stiffness, and paralysis that can lead to permanent disability and death.
__________
_______________
Initial
Date
Measles: I understand by not receiving the Measles vaccine, my child is at risk of developing a rash, high fever, cough, runny nose, red,
watery eyes, diarrhea, ear infections, pneumonia, encephalitis, seizures, and death.
__________
_______________
Initial
Date
Mumps: I understand by not receiving the Mumps vaccine, my child is at risk of developing a fever, headache, muscle aches, swelling
of the lymph nodes close to the jaw, meningitis, inflammation of the testicles or ovaries, sterility, arthritis, inflammation of the pancreas
and deafness (usually permanent).
__________
_______________
Initial
Date
Rubella (German Measles) I understand by not receiving the Rubella vaccine, my child is at risk of developing a rash and fever in
children and young adults, birth defects if acquired while pregnant include deafness, cataracts, heart defects, mental retardation, and
liver and spleen damage.
__________
_______________
Initial
Date
Hepatitis B: I understand by not receiving the Hepatitis B vaccine, my child is at risk of developing yellow skin or eyes, tiredness,
stomachaches, loss of appetite, nausea, or joint pain, life-long liver problems, such as scarring of the liver and liver cancer.
__________
_______________
Initial
Date
Haemophilus Influenza type b (Hib): I understand by not receiving the Hib vaccine, my child is at risk of developing skin and throat
infections, meningitis, pneumonia, sepsis, arthritis, permanent brain damage and possible death.
__________
_______________
Initial
Date
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Adapted from the American Academy of Pediatrics and the Centers for Disease Control and Prevention
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