Immunization Exemption Letter Template printable pdf download

Immunization Exemption Letter Template

IMMUNIZATION EXEMPTION LETTER

[YOUR NAME]

[YOUR STREET ADDRESS]

[YOUR CITY, STATE, ZIP CODE]

Thursday, April 06, 2017

To Whom It May Concern:

Re: Pennsylvania Vaccination Requirements - Religious Exemption

We, ___________________________________________________________ , being the legal guardians

of ___________________________________________________________ object to the immunization

requirements as outlined by the Department of Health of the Commonwealth of Pennsylvania as

defined in 28 PA. CODE CH.23 on the basis of a religious belief/strong moral or ethical conviction

outlined in section § 23.84 Exemption from immunization.

Sincerely,

§ 23.84. Exemption from immunization. [28 PA. CODE CH.23]

Source:

(a) Medical exemption. Children need not be immunized if a physician or the physician's

designee provides a written statement that immunization may be detrimental to the health of the child.

When the physician determines that immunization is no longer detrimental to the health of the child,

the child shall be immunized according to this subchapter.

(b) Religious exemption. Children need not be immunized if the parent, guardian or

emancipated child objects in writing to the immunization on religious grounds or on the basis of a

strong moral or ethical conviction similar to a religious belief.

Immunization Exemption Letter Template