Refusal To Vaccinate

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Refusal to Vaccinate
Select the vaccine(s) that you do not want your child or self to receive from the following list.
{ } Diphtheria/Tetanus/Pertussis (DTaP)
{ } Pertussis
{ } Polio (IPV)
{ } Haemophiius influenzae Type b (Hib)
{ } Hepatitis B (Hep B)
{ } Tetanus/Diphtheria (Td)
{ } Measles/Mumps/Rubella (MMR) { } Varicella (Chickenpox)
I have received and reviewed the medical information from the Centers for Disease Control and Prevention
discussing the risks and alleged benefits of vaccination.
I understand the following:
· The alleged purpose of and the alleged need for the recommended vaccine(s)
.
The risks and alleged benefits of the reco mmended vaccine(s)
·
If my child/I do(es) not receive the vaccine(s), the consequences may include-
contracting
- the disease the vaccine is alleged to prevent
- transmitting the disease to others
-
the alleged need for my child/self to stay out of daycare, school, college or
university during an outbreak for which my child is/I am not vaccinated
·
That I may contact my child's or my personal physician or the Arkansas
Department of Health and Human Services, at 501-661-2169, for answers
to all of my questions regarding the recommended vaccine(s)
· That I may reconsider and accept vaccination for my child/self anytime
in the future. The Arkansas Department of Health and Human Services,
the American Academy of Pediatrics, the American Academy of Family
Physicians, and the Centers for Disease Control and Prevention all
strongly recommended that the vaccine(s) be given.
I have decided to decline the vaccine(s) recommended, as indicated above, by checking the appropriate box(es).
Under penalty of law, I affirm that I have received and reviewed the enclosed medical information and the risks
associated with my child/me being vaccinated as stated in this information and still request an exemption
from the vaccine(s).
Signature_____________________________________________
Parent/Guardian or College/University Student
3

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