Certificate Of Exemption Page 2


Certificate of Exemption
For Religious Membership
Exemption ONLY
NOTICE: Complete this side if you belong to a church or religion that objects to the use of
medical treatment.
If you have a religious objection to vaccinations, but the beliefs or teachings of your church
or religion allow for your child to be treated by medical professionals such as doctors and
nurses, then you must use Side A of this Certificate of Exemption.
In order for this form to be legally valid for religious membership reasons, please:
Step 1: Fill in your child’s information in Boxes 1-4
Step 2: Read the Parent/Guardian Declaration and provide your initials where indicated
Step 3: Provide the name of the church or religion of which you are a member, and print your
name, sign, and date in Boxes 5-7
1. Child’s Last Name
2. Child’s First Name and Middle Initial
3. Birthdate (mm/dd/yyyy)
4. Gender
I am the parent or legal guardian of the above named child and I am exempting my child from all
required vaccinations.
Parent/Guardian Declaration
I understand that:
 My child may not be allowed to attend school or child care during an outbreak of the disease that my
child has not been fully vaccinated against. ______ (initial)
 Exempting my child from all required vaccines may result in serious illness, disability, or death to my child or
others. I understand the risks and possible outcomes of my decision to exempt my child. ______ (initial)
 The information provided on this form is complete and correct. ______ (initial)
I affirm that I am a member of a church or religion whose teachings preclude healthcare practitioners from
providing any medical treatment to my child.
5. Name of Church or Religion of Which You Are a Member
6. Print Parent/Guardian Name
7. Parent/Guardian Signature and Date
RCW 28A.210.090 “The parent of legal guardian demonstrates membership in a religious body or a church in which the religious beliefs or teachings of
the church preclude a health care practitioner from providing medical treatment to the child.”
If you have a disability and need this form in a different format please call 1-800-525-0127 (TDD/TTY Call 711)


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