California Personal Beliefs Vaccine Affidavit Form printable pdf download

Exemption From Immunizations

AFFIDAVIT TO BE SIGNED BY PARENT OR GUADIAN

I request exemption of my child _________________________________________ from the

immunization requirements for school entry because these immunizations are contrary to my

personal beliefs. I understand that in a case of an outbreak of any of the diseases listed in

subdivision (a) of Section 120335 that my child may be temporarily excluded from school for his

or her protection.

_______________________________________________

_________________

Print Name

Date

_______________________________________________

Signature

California Health & Safety Code

IMMUNIZATION NOT REQUIRED WHEN CONTARY TO PERSONAL BELIEFS

Immunization of a person shall not be required for admission to a school or other institution

listed in Section 120335 if the parent or guardian or adult who has assumed responsibility for his

or her care and custody in case of a minor, or the person seeking admission if an emancipated

minor, files with the governing authority a letter or affidavit stating that immunization is contrary

to his or her beliefs. However, whenever there is good cause to believe that the person has been

exposed to one of the communicable diseases listed in subdivision (a) of Section 120335, that

person may be temporarily excluded from the school or institution until the local heath officer is

satisfied that the person is no longer at risk of developing the disease.

(Added by Stat. 1995, Ch. 415, Sec 7)

California Health & Safety Code

MEDICAL CONDITIONAL MAKING IMMUNIZATION UNSAFE

If the parent or guardian files with the governing authority a written statement by a licensed

physician to the effect the physical condition of the child is such, or medical circumstances

relating to the child are such, that immunization is not considered safe, indicating the specific

nature and probable duration of the medical condition or circumstances that contraindicate

immunization, that person shall be exempt from the requirements of Chapter 1, (commencing

with Sections 120325, but excluding Section 120380) and Sections 120400, 120405, 120410, and

10415 to the extent indicated by the physician’s statement.

California Personal Beliefs Vaccine Affidavit Form