State Of Alaska Religious Exemption Form printable pdf download

State of Alaska Religious Exemption Form

Effective July 1, 2013

This official State form is required for all religious exemptions

Children in Alaska public and private schools, preschools and child care facilities must be immunized in

accordance with Alaska Administrative Codes 7 AAC 57.550 for child care affirming that immunization

conflicts with the tenets and practices of the church or religious denomination of which the parent or guardian

is a member; or 4 AAC 06.055 for school affirming that immunization conflicts with the tenets and practices of

the church or religious denomination of which the applicant is a member.

(NOTE: Personal or philosophical exemptions are not allowed under Alaska regulations.)

If a religious exemption is applicable, the child’s parent/guardian must complete the information below and

return this form to the school, preschool, or child care facility. The form is required to be notarized and

renewed annually.

__________________________________________________________________________________________

Name of Child

Birth date

I/We affirm that immunization conflicts with the tenets and practices of the church or religious

denomination of which the applicant/parent/guardian is a member. I/We understand that if there is an

outbreak of a vaccine-preventable disease that my child has not been fully immunized against, my

child may be at risk for disease and may be excluded from school or child care until he/she is

determined to no longer be at risk of developing the disease.

________________________________

__________________

___________________

Signature of Parent(s) or Guardian(s)

Telephone

Date

(Form valid from July 1 through June 30)

State of _____________________________

Judicial District ______________________________ SS.

The Foregoing Instrument was acknowledged before me by

_________________________________________ on this ________ day of

_________________________________________ , 20 __________ .

Witness my hand and seal.

________________________________________

Notary Public (Signature)

________________________________________

Notary’s printed name

__________________________________________

Notary’s city

My commission expires

_________________

Revised 3/2013

State Of Alaska Religious Exemption Form