Fillable Certificate Of Exemption printable pdf download

CERTIFICATE OF EXEMPTION

Please read instructions on the reverse of this certificate before completing.

All entries must be legible or form will be returned. Please print unless signature is required.

_______________________________________________

____________________ ________________________________________________________

Name of Child (Last, First, MI)

Birth Date

Name of School / Child Care Facility / Head Start

_____________________________________

______________ _________ ________________________ _____________________________

Parent/Guardian’s Name

School Year

Grade

Facility Phone Number

School District

_______________________

___________________________________

__________________________________

___________

Parent Phone Number

County

City

Zip

TYPE OF EXEMPTION

(Complete either section 1, 2 or 3 and sections 4 & 5)

MEDICAL CONTRAINDICATION:

I hereby certify that the immunization(s) specified below are medically contraindicated for the above named child.

_______________________________________________________

________________________________________________________

Immunization(s)

State the condition that would endanger the life or health of the child.

____________________________________________

_______________________________________________________

Printed name of Physician

Signature of Physician

_________________________________________________ _______________________________________________________

Address of Physician

Phone number of Physician

RELIGIOUS OBJECTION:

I hereby certify that immunization is contrary to the teachings of the above named child’s religion.

___________________________________________________

Printed name of Religious Leader or Parent/Guardian

Signature of Religious Leader or Parent/Guardian

PERSONAL OBJECTION:

I hereby certify that immunization is contrary to my beliefs. As the parent or legal guardian of the above named child, I request an

exemption to the immunization requirements for School, Child Care Facility or Head Start attendance. I have written a brief summary

of my objections in the space provided below. I understand that lost records are not grounds for an exemption.

REQUIRED: Summary of Objections: (Limited to 600 characters.)

___________________________________________________________________________________________________________________________

Please check which immunizations this exemption applies to:



DTaP/Td/Tdap

Hib

Polio

(Diphtheria, Tetanus & Pertussis)

(Haemophilus Influenzae type B)



Hepatitis A

MMR

Varicella (Chickenpox)

(Measles, Mumps and Rubella)



Hepatitis B

All

Pneumococcal

Acknowledgement

I understand that in the event of a disease outbreak in the School, Child Care Facility or Head Start, my child may have to be excluded

for his/her protection and for the protection of the other children in the School, Child Care Facility or Head Start.

_________________________________________________

________________________________________________ ____________________

Printed name of Parent/Guardian

Signature of Parent/Guardian

Date

ATTENTION: PARENT/GUARDIAN – This form is to be submitted to the School, Child Care Facility or Head Start.

This section reserved for use by OSDH.

The School, Child Care Facility or Head Start should keep a copy of this form and mail the original to:

Oklahoma State Department of Health

Immunization Service - 0306

tth

1000 N.E. 10

Street

Oklahoma City, Oklahoma 73117-1299

For Questions Call: 405-271-4073

ODH Form 216-A (Revised 08/12)

Oklahoma State Department of Health

For forms, visit:

__________________ ______

Certificate Of Exemption

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