Religious Exemption Form printable pdf download

Religious Exemption Form

STUDENTS

# 5141.3

Form 2

RELIGIOUS EXEMPTION FORM

Children with religious exemptions shall be permitted to attend school except in the case of a

vaccine-preventable disease outbreak in the school. All susceptible students will be excluded

from school based on public health officials’ determination that the school is a primary site for

disease exposure, transmission and spread into the community. Students excluded from school

for this reason will not be able to return to school until (1) the danger of the outbreak has passed

as determined by public health officials, 92) the student becomes ill with the disease and

completely recovers, or (3) the student is immunized. For example, for measles the complete

incubation period is 18 days from the onset of symptoms for the last case in the community.

Outbreaks like measles may last for several months.

According to State statutes (Connecticut General Statutes Sections 19a-7f and 10-204a), no child

may be admitted school without proof of immunization or a statement of exemption. Parents or

guardians seeking an exemption on the basis that immunizations would be contrary to religious

beliefs of the child should complete the following statement and return it to the school nurse.

To Whom It May Concern:

As the parent(s)/guardian(s) of ____________________________________________________.

(Name of Student)

I/we hereby assert that the immunization of this student would be contrary to the religious beliefs

of this child. Therefore, this child shall be exempt from the required immunizations under

Section 10-204a of the Connecticut General Statutes and shall be permitted to attend school

except in the case of a vaccine-preventable disease outbreak in the school.

_________________________________

___________________

Signature of Parent(s)/Guardian(s)

Date

_________________________________

___________________

Signature of Parent(s)/Guardian(s)

Date

_____________________________________________________________

Address

_____________________________________________________________

Telephone #

Litchfield Board of Education

Form adopted:

November 30, 2011

Religious Exemption Form