Medical Exemption To Mandatory Immunizations
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2Medical Exemption to Mandatory Immunizations
For Child Caring Facilities and Schools
Wyoming Statutes 21‐4‐309 (b), 14‐4‐116 (c) and the Wyoming Immunization Rules and Regulations for School Immunizations
require that any person attending a public or private school or child caring facility shall provide proof of immunization within 30 days
upon entry, unless an approved immunization exemption has been granted.
Submit exemption requests to your local County Health Officer (list available at ), or to the State
Health Officer at: Wyoming Department of Health, 6101 Yellowstone Road, Suite 420, Cheyenne, WY 82002, Attn: Immunization
Exemptions.
Please complete all fields; incomplete forms will not be approved. One form must be submitted for each child. Exemptions requests
shall be renewed in accordance with the Wyoming Immunization Rules and Regulations for School Immunizations.
Child Information
First Name:
Middle Name:
Last Name:
Sex:
Female
Male
Date of Birth:
Parent/Guardian Information
Check if you are an emancipated minor or over 18 years old.
First Name:
Last Name:
Relationship to child:
Mailing Address:
City:
State:
Zip:
Email Address:
Phone Number:
How would you like to receive the determination made on this Immunization Exemption? Mail to Me I’ll Pick Up
PHYSICIAN’S STATEMENT
Not applicable, see attached Physician’s Statement
List each vaccine declined
List medical contraindication(s) for each vaccine declined
The physical condition of the above named child is such that vaccination would endanger his/her life or health or is medically
contraindicated due to other medical conditions.
Physician’s Name (printed):____________________________________ Signature: ________________________________________
Date: ______________
License Number: ___________________
State of Licensure: ____________________
Wyoming Department of Health
Page 1 of 2
Medical Exemption to Mandatory Immunizations
Rev. 10/1/2016
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