Ohio 4h Camps Immunization Exemption Form printable pdf download

Ohio 4h Camps Immunization Exemption Form

OHIO STATE UNIVERSITY EXTENSION

Ohio 4-H Camps

Immunization Exemption Form

I, the parent or guardian of ___________________________________, state that my

child would like to participate in the 4-H Camp, ________________________________,

and has not received the following immunizations:

(

) Diphtheria / Tetanus / Pertussis

(

) Hepatitis B

(

) Polio

(

) Haemophilus Influenza Type B

(

) Measles/Mumps/Rubella

(

) Varicella (Chicken Pox)

My child has not received the immunizations above because: _____________________

______________________________________________________________________

By signing below, I acknowledge that during the course of an outbreak of any of

the aforementioned diseases that my child may be subject to exclusion from camp

for the duration of the outbreak for health and safety reasons at the sole discretion

of OSU Extension.

Parent/Guardian Printed Name: ____________________________________________

Parent / Guardian Signature: ______________________________________________

Date: _________________________________________________________________

{00255576-1}

CFAES provides research and related educational

programs to clientele on a nondiscriminatory basis. For

more information: go.osu.edu/cfaesdiversity.

Updated 2/25/15

Ohio 4h Camps Immunization Exemption Form