Certificate Of Exemption (Page 2 of 2) in pdf

SIDE B:

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.

PARENT OR GUARDIAN INSTRUCTIONS

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)

Certificate Of Exemption Page 2