Notarized Affidavit Required Per 14 Del. Code Sec. 131

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NOTARIZED AFFIDAVIT REQUIRED PER 14 DEL. CODE SEC. 131
AFFIDAVIT OF RELIGIOUS BELIEF
STATE OF DELAWARE
………. COUNTY
1.
(I) (We) (am) (are) the (parent[s]) (legal guardian[s]) of _______________________
Name
of
Child
2.
(I) (We) hereby (swear) (affirm) that (I) (we) subscribe to a belief in a relation to a Supreme
Being
involving
duties
superior
to
those
arising
from
any
human
relation.
3.
(I) (We) further (swear) (affirm) that our belief is sincere and meaningful and occupies a place in
(my)
(our)
life
parallel
to
that
filled
by
the
orthodox
belief
in
God.
4.
This belief is not a political, sociological or philosophical view of a merely personal moral code.
5.
This belief causes (me) (us) to request an exemption from the mandatory school vaccination
program for Name of Child,
.
6.
(I) (We) acknowledge that, in the event that the Division of Public Health declares that there is an
outbreak of a vaccine preventable disease, or if in the estimation of the Division of Public Health,
(my) (our) child has had, or is at risk of having an exposure to a vaccine preventable disease,
(my) (our) child shall be temporarily excluded from attendance at the public school, in which
case, it will be (my) (our) responsibility, along with the school, to assist (my) (our) child in
keeping up with school work, and (my) (our) child shall be authorized to return to school once
approved by the Division of Public Health.
7.
(I) (We) acknowledge that (I) (we) have been given the opportunity to receive from the school
district information regarding the medical benefits and risks in choosing whether to have the child
participate in the immunization program, and if (I) (we) have not taken that opportunity, it is
hereby waived.
___________________________________
Signature of Parent(s) or Legal Guardian(s)
SWORN TO AND SUBSCRIBED before me, a registered Notary Public, this
day of
,
.
(Seal)
Notary Public
My commission expires: _______________

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