Boothbay Region Elementary Immunization Exemption Form printable pdf download

Boothbay Region Elementary Immunization Exemption Form

Boothbay Region Elementary School

Telephone: 207-633-5097

Fax: 207-633-7130

238 Townsend Avenue

Boothbay Harbor, ME 04538

Mark Tess, Principal

Brandon Ward, Assistant Principal

IMMUNIZATION EXEMPTION FORM 

As a parent/guardian of __________________________________________in grade ___________

(student name)

and date of birth _______________________, I am requesting a waiver for the following

immunizations:

All required immunizations:   ☐

Specific immunizations: DTAP ☐

I/OPV ☐

MMR☐

Varicella ☐

I understand that in the case of an outbreak of the specific disease for which my

child is not protected, my child will be kept out of school and school activities. The

length of time my child will be kept out of school may vary from a week to over a

month depending on the disease and length of the outbreak. I also understand that if

my child is kept out of school, the school is not required to provide off-site classes or

tutoring. The school may make reasonable accommodations to assist my child in

keeping up with classwork.

I am requesting a waiver for:

Sincere Religious Belief ☐

Philosophical Reason ☐ Medical

☐

Exemption

My explanation is as follows:

_________________________________________________________________________________________________

________________________________________________

Signature: _______________________________________________ Date:____________________________

Physician’s Signature: _________________________________________________Date: ____________

(required for medical exemption only)

Boothbay Region Elementary Immunization Exemption Form