Sample Request For Exemption From Immunizations For Reasons Of Conscience


Sample Request for Exemption from Immunizations for Reasons of Conscience
In order to expedite your request, please print or type the name
and date of birth for each child. If you are submitting this request
by fax, please provide your telephone number so that we can
Date: _________________
contact you if there is a problem with the fax transmission.
Thank You.
I wish to obtain an Exemption from Immunizations for Reasons of Conscience Affidavit Form. Please provide me with an
exemption affidavit form for each of my children listed below (maximum 5 forms per child):
Name of Parent/Legal Guardian:
Mailing address:
Apartment Number:
Telephone Number (
Needed for faxed requests
Signature of Parent or Legal Guardian
Birth date
First Name
Middle Name
Last Name
of forms
Please mail, fax, or hand deliver your request to:
Mailing Address:
Hand Deliver:
Department of State Health Services
Department of State Health Services
Immunization Branch (MC 1946)
Immunization Branch (MC-1946)
P.O. Box 149347
1100 West 49
Austin, TX 78714-9347
Austin, TX 78756
Fax (512) 458-7544
Please provide all information requested to expedite your request. Thank you.
Texas Department of Health Services
Stock No. EF11-13140
Immunization Branch
Rev. 03/09


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