Refusal To Vaccinate (Page 2 of 2) in pdf

Refusal To Vaccinate Page 2

Statement of Understanding

I have signed the statement of refusal to vaccinate. I understand that at the discretion of the Arkansas

Department of Health and Human Services, any non-immunized individual may be removed from the facility for

which he/she is attending during a vaccine-preventable disease outbreak. I further understand that the

individual shall not return to the facility until the outbreak has been resolved and the Arkansas Department of

Health and Human Services approves his/her return.

Signature________________________________________

Parent/Guardian or College/University Student

Notary Public

State of _______________County of_________________ on this_________day of________________ , 2006,

personally appeared before me the said named (parent/Guardian or College/University Student)

____________________________________known to me to be the person described therein and who executed

the foregoing instrument and he/she executed the same and duly sworn by me, made oath that the statements in

the application are true.

Signature of Notary Public_______________________________________________

My commission expires___________________________________________

Seal

Mail to:

Arkansas Department of Health and Human Services

Exemptions

4815 West Markham #48

Little Rock, AR 72205

09/05

Refusal To Vaccinate Page 2