Immunization Exemption printable pdf download

Immunization Exemption

Regional School Unit 21

Arundel, Kennebunk, Kennebunkport , Maine

Immunization Exemption

The Maine Department of Human Services and Maine Department of Education require that

an immunization exemption be filled out and signed at the beginning of every school year.

Please complete and return to the school nurse as soon as possible.

As parent/legal guardian of _______________________ date of birth , _______,

I am requesting a waiver for the following immunizations:

____ Diphtheria

____ Tetanus ____ Pertussis

____ Polio

____ Measles

____ Mumps

____ Rubella

____ Varicella

I understand that in case of an outbreak of a specific disease, for which my child is not

protected, my child will be kept out of school and all school activities. The length of time

my child will be kept out of school may vary from week to weeks to over a month,

depending on the disease and the length of the outbreak. I also understand that if my child

is kept out of school, the school is not required

to provide off campus classes or tutoring. The school may make reasonable

accommodations to assist my child in keeping up with class work.

I am requesting a waiver for (check one) ____ sincere religious belief

____ philosophical reason

My explanation is as follows:

Signature of parent/legal guardian _____________________________________

Relationship to student ____________________________ Date_____________

School Immunization Law , Title 20-A MRSA, Chapter 223, subsections 6352-6358.

Immunization Exemption