Certificate Of Exemption printable pdf download

SIDE A:

Certificate of Exemption

For Religious, Personal,

Philosophical, and Medical

DOH 348-106 Jan 2015

Exemptions

PART 1: PARENT OR GUARDIAN INSTRUCTIONS

PART 2: HEALTHCARE PROVIDER INSTRUCTIONS

In order for this form to be valid for religious,

In order for this form to be valid, please:

personal, philosophical, or medical reasons,

Step 1: Mark which disease(s) and what type of

exemption is requested. If medical write a

please:

T for Temporary or P for Permanent.

Step 1: Fill in your child’s information in Boxes 1-4

Step 2: Discuss the benefits and risks of

Step 2: Read the Parent/Guardian Declaration

immunizations with the parent or guardian

Step 3: Provide your initials where indicated

Step 3: Read the Provider Declaration

Step 4: Print your name, sign, and date in Boxes 5-6

Step 4: Print your name, credentials, sign, and date

Step 5: Have a provider complete Part 2 of this

in Boxes 7-8

form

Expiration

1. Child’s Last Name

Personal/

Medical

Vaccine

Date for

Religious

Philosophical

(T/P)

Temporary

Medical

Diphtheria

2. Child’s First Name and Middle Initial

Hepatitis B

Hib

Measles

3. Birthdate (mm/dd/yyyy)

4. Gender

Mumps

Male

________

________________

Pertussis

Female

Pneumococcal

I am the parent or legal guardian of the above

named child. One or more required vaccines

Polio

are in conflict with my personal, philosophical,

Rubella

or religious beliefs.

Tetanus

Parent/Guardian Declaration

Varicella

All

I understand that:

**A provider may grant a medical exemption only if

 My child may not be allowed to attend school or

there is a medical contraindication to a vaccine.

child care during an outbreak of the disease

that my child has not been fully vaccinated

against. ______ (initial)

Provider Declaration

 Exempting my child from any or all required

I declare that:

vaccine(s) may result in serious illness, disability,

 I have discussed the benefits and risks of

or death to my child or others. I understand the

immunizations with the parent/legal guardian as a

risks and possible outcomes of my decision to

condition for exempting their child.

exempt my child. ______ (initial)

 I am a qualified MD, ND, DO, ARNP or PA

 The information provided on this form is

licensed under Title 18 RCW.

complete and correct. ______ (initial)

 The information provided on this form is complete

and correct.

5. Print Parent/Guardian Name

7. Print Provider Name and Credential

(

MD, ND, DO, ARNP, PA)

6. Parent/Guardian Signature and Date

8. Provider Signature and Date

____ /____ /____

RCW 28A.210.080-090 “Before or on the first day of every child’s attendance at any public and private school or licensed child care center in Washington State,

the parent or guardian must present proof of either: (1) full immunization, (2) the initiation of and compliance with a schedule of immunization, as required by rules

of the State Board of Health, or (3) a certificate of exemption signed by a parent or guardian and is either A) signed by a licensed healthcare provider or B)

demonstrates membership in a church or religious body that precludes healthcare practitioners from providing medical treatment to children.”