Student Exemption From Mandatory Immunization In New Jersey (Page 2 of 3) in pdf

Student Exemption From Mandatory Immunization In New Jersey Page 2

What follows is a Sample Exemption Letter for use in New Jersey:

Date :

The undersigned is the parent or guardian of _________________________.

The State Sanitary Code (26:1A-9.1) provides for "exemption for pupils from mandatory

immunization if the parent or guardian of the pupil objects thereto in a written statement signed

by the parent or guardian upon the ground that the proposed immunization interferes with the

free exercise of the pupil's religious rights."

I do therefore hereby certify that the proposed immunization interferes with the free exercise of

the child's religious rights. The administration of immunizing agents conflicts with the child's

exercise of religious tenets or practices in that we object to the administration of such agents by

injection or orally based upon our religious beliefs.

_____________________________

Signature of Parent or Guardian

ACKNOWLEDGMENT

state of New Jersey

county of _________________:

On this _______ day of ______________, 200__, before me

personally appeared __________________________________, to me known to be the person

described in and who executed the foregoing instrument and acknowledged that he executed

the same as his free act and deed, for the purposes therein set forth.

_______________________________________

(Notary Public)

My Commission Expires ______________________________, 200___

Student Exemption From Mandatory Immunization In New Jersey Page 2