Statement Of Exemption From Vaccination And Immunization (Preschool/daycare) printable pdf download

Statement Of Exemption From Vaccination And Immunization (Preschool/daycare)

Statement of Exemption from Vaccination and

Immunization (preschool/daycare)

I, _____________________________________, as parent (or guardian) having responsibility for

_______________________________, a minor enrolled in the ___________________________

Preschool/Daycare, state that said minor is exempt from Ohio state vaccination and

immunization requirements on religious and/or philosophical grounds, in accordance with Ohio

state law 5104.014 ( C ) (1) ( b ), quoted below:

Signed __________________________________________________

Address _________________________________________________

_________________________________________________

Date __________________

“A child is not required to be immunized against a disease specified in division (B) of this

section [Chicken pox, Diphtheria, Haemophilus influenzae type b, Hepatitis A, Hepatitis B,

Influenza, Measles, Mumps, Pertussis, Pneumococcal disease, Poliomyelitis, Rotavirus, Rubella,

Tetanus] if any of the following is the case: The child’s parent or guardian has declined to have

the child immunized against the disease for reasons of conscience, including religious

convictions.”

Statement Of Exemption From Vaccination And Immunization (Preschool/daycare)