Idaho Certificate Of Immunization Exemption Form (Page 2 of 2) in pdf

SECTION 2:

Please select ONE of the following exemption types (medical, religious, philosophical) for vaccines checked in Section 1.

(This exemption requires the signature of a licensed physician)

MEDICAL EXEMPTION



As the child’s physician, I certify that the physical condition of this child is such that the immunization(s) checked in Section 1 would endanger

the health of the child.

 This medical exemption is permanent.

 This medical exemption is temporary. Duration of temporary exemption: _______/_______/________

I hereby request that this child be exempted from the Immunization Requirements for Idaho School Children (IDAPA 16.02.15) due to a

medical condition for which immunizations are contraindicated.

__________________________________________

________________________________________

_____________________

Name of Physician (PRINT)

Signature of Physician

Medical License #

Date

As the child’s parent/guardian, I understand that in the event of a disease outbreak my child may be excluded from school for the duration of

the outbreak, both for his/her own protection and for the protection of others. I acknowledge that I have read this document in its entirety.

__________________________________________

________________________________________

_____________________

Name of Parent/Guardian (PRINT)

Signature of Parent/Guardian

Date

__________________________________________

_________________________

Full Name of Exempted Child (PRINT)

Child’s Date of Birth (Month, Day, Year)



RELIGIOUS EXEMPTION

As the child’s parent/guardian, I certify that I am a member of a recognized religious organization which has doctrine that opposes

immunizations for the following reason(s):

________________________________________________________________________________________________________________

I understand that in the event of a disease outbreak my child may be excluded from school for the duration of the outbreak, both for his/her

own protection and for the protection of others. I acknowledge that I have read this document in its entirety.

__________________________________________

________________________________________

_____________________

Name of Parent/Guardian (PRINT)

Signature of Parent/Guardian

Date

__________________________________________

_________________________

Full Name of Exempted Child (PRINT)

Child’s Date of Birth (Month, Day, Year)

PHILOSOPHICAL EXEMPTION



As the child’s parent/guardian, I am opposed to having my child receive the immunization(s) checked in Section 1 of this form for the following

reason(s):

________________________________________________________________________________________________________________

I understand that in the event of a disease outbreak my child may be excluded from school for the duration of the outbreak, both for his/her

own protection and for the protection of others. I acknowledge that I have read this document in its entirety.

__________________________________________

________________________________________

_____________________

Name of Parent/Guardian (PRINT)

Signature of Parent/Guardian

Date

__________________________________________

_________________________

Full Name of Exempted Child (PRINT)

Child’s Date of Birth (Month, Day, Year)

Page 2 of 2

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Idaho Certificate Of Immunization Exemption Form Page 2

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