Medical Exemption To Mandatory Immunizations Page 2
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2Child’s Name: ______________________________________
I _______________________________________, request a medical exemption to the mandatory school immunizations for
(Name of Parent/Guardian)
___________________________________, based on the medical reasons outlined above or in the attached physician’s statement.
(Name of Child)
By signing this form, I am declining the vaccine(s) required for school entry for my child/myself, due to medical contraindications. I
understand that my child/I will not be allowed to attend child care or school during a disease outbreak when declared by the State
or County Health Officer.
The information I have provided on this form is complete and accurate. I acknowledge that I have read this document in its entirety
and fully understand it. I also understand that it is my responsibility to retain the original exemption and provide a copy to the
school or child caring facility.
_________________________________________________________________ _ ___
_________________________________
Signature of Parent/Guardian/Student (emancipated or over 18 yrs old)
Date
Check this box to exclude this exemption from being entered into the Wyoming Immunization Registry. Please be advised that you will be
responsible for maintaining your child’s/your immunization records to ensure child care or school compliance.
NOTARY ACKNOWLEDGEMENT
State of ____________________________________
County of __________________________________
Subscribed and sworn on this _________ day of _______________, 201___, by the above named person
_________________________________________, known by me, or proven to be the person named as the Parent/Guardian
Place Seal or Stamp Below
in the above Religious Exemption to Mandatory Immunizations.
______________________________________________________________
Signature of Notarial Officer
My commission expires
____________________________________
Expiration Date
EXEMPTION DETERMINATION (FOR USE BY THE COUNTY OR STATE HEALTH OFFICER ONLY)
Approved
Not Approved
If a request is not approved, a denial letter and this form must be returned to the Parent/Guardian. A new
request will need to be submitted. Revisions cannot be made to this same form and resubmitted.
_____________________________________________________
____________________________
Signature of County or State Health Officer
Date
Wyoming Department of Health
Page 2 of 2
Medical Exemption to Mandatory Immunizations
Rev. 10/1/2016
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