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SAMPLE REQUEST FOR RELIGIOUS EXEMPTION TO IMMUNIZATION FORM

PARENT/GUARDIAN STATEMENT

Name of Student______________________________________________________________

Identification Number__________________________________________________________

Name of Parent(s)/Guardian(s)___________________________________________________

School District and Building Name________________________________________________

This form is for your use in applying for a religious exemption to Public Health Law immunization

requirements for your child. Its purpose is to establish the religious basis for your request since the

State permits exemptions on the basis of a sincere religious belief. Philosophical, political,

scientific, or sociological objections to immunization do not justify an exemption under Department

of Health regulation 10 NYCRR, Section 66-1.3 (d), which requires the submission of:

A written and signed statement from the parent, parents, or guardian of such child, stating

that the parent, parents or guardian objects to their child’s immunization due to sincere and

genuine religious beliefs which prohibit the immunization of their child in which case the

principal or person in charge may require supporting documents.

In the area provided below, please write your statement. The statement must address all of the

following elements:

 Explain in your own words why you are requesting this religious exemption.

 Describe the religious principles that guide your objection to immunization.

 Indicate whether you are opposed to all immunizations, and if not, the religious basis that

prohibits particular immunizations.

You may attach to this form additional written pages or other supporting materials if you so choose.

Examples of such materials are listed on page 3.

_________________________________________________________________________________

Please continue your statement on page 2

March 2016

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Sample Request For Religious Exemption To Immunization Form - Parent/guardian Statement