Sample Request For Exemption From Immunizations For Reasons Of Conscience printable pdf download

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:

City/State/Zip:

Telephone Number (

)

Needed for faxed requests

Signature of Parent or Legal Guardian

Birth date

Number

First Name

Middle Name

Last Name

(mm/dd/yyyy)

of forms

Please mail, fax, or hand deliver your request to:

Mailing Address:

Hand Deliver:

Department of State Health Services

Immunization Branch (MC 1946)

Immunization Branch (MC-1946)

P.O. Box 149347

1100 West 49

Street

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

Sample Request For Exemption From Immunizations For Reasons Of Conscience