Sample Form Religious Exemption Statement printable pdf download

Sample Form Religious Exemption Statement

SAMPLE FORM

Religious Exemption Statement

__________________________________________

(Printed full, legal name of child)

I, the undersigned, do hereby swear or affirm, as the case may be as follows:

1. I am making this Religious Exemption Statement pursuant to Conn. Gen. Stat. § 19a-79 so that

the child may enroll in child care at

________________________________________________________.

□

2. I am the lawful

parent

guardian of the child.

□

3. Immunizing said child would be contrary to the

child’s

parent’s

guardian’s religious

beliefs.

4. I understand that by claiming this exemption the child shall be exempt from one or more of the

immunizations required by Conn. Gen. Stat. §§ 19a-79 and 19a-7f.

5. I understand that during a vaccine-preventable disease outbreak at the above-identified child care

program, all susceptible children, including the child named above will be excluded from the

child care program if a public health official determines that the program is a significant site for

disease exposure, transmission and spread into the community. In such case, such children,

including the named child shall be excluded from the program until: (1) the public health official

determines that the outbreak danger has ended; (2) the child becomes ill with the disease and

completely recovers from it; (3) the child is vaccinated according to public health protocol; or (4)

the child has proof of immunity to the disease.

______________________________

________________________

_______________

Name(s) of Parent(s)

Signature of Parent(s)/Guardian(s)

Date

______________________________

________________________

_______________

Name(s) of Parent(s)

Signature of Parent(s)/Guardian(s)

Date

________________________________________ __________________________________________

Address (Street & House or Apt. Number)

Telephone Number

________________________________________

City, State and Zip Code

TO CLAIM A RELIGIOUS EXEMPTION, AN EXEMPTION FORM MUST BE SUBMITTED

TO THE CHILD CARE PROGRAM ANNUALLY.

Sample Form Religious Exemption Statement

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