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Physical Examinations & Immunizations

Admin. Procedure 6.402.4

Vaccination(s) Refusal Due to Personal Religious Beliefs Form

Child’s Name___________________________________ Parent/Guardian Name____________________

Address________________________________________ State ____________________ZIP__________

Phone_________________________

I have been advised my child or ward (named above) should receive the following vaccines but I am

declining to have my child immunized.

Declined (Check all that apply)

Hepatitis B Vaccine

Measles, Mumps, Rubella Vaccine (MMR)

Diphtheria, Tetanus, acellular Pertussis Vaccine

Varicella (Chickenpox) Vaccine

(DTaP)

Diphtheria, Tetanus Vaccine (DT and Td)

Influenza (flu) Vaccine

Haemophilus influenza type B Vaccine (Hib)

Meningococcal Vaccine

Pneumococcal Conjugate Vaccine (PCV)

Hepatitis A Vaccine

Polio Vaccine (IPV)

Other: ____________________________

I have been given the opportunity to read the Centers for Disease Control and Prevention’s (CDC)

Vaccine Information Sheet(s) (VIS) explaining the above vaccine(s) and the disease(s) they prevent. I

have had the opportunity to discuss these with my child’s health care provider or the health department

and to have my questions, if any, answered. By signing below, I acknowledge I understand the following:

The purpose and the need for the recommended vaccine(s)

•

The risks and benefits of the recommended vaccine(s)

•

If my child does not receive the vaccine(s), I accept the consequences of my decision,

•

which may include:

My child contracting the illness the vaccine should prevent

My child transmitting the disease to others

The need for my child to stay out of daycare or school during disease outbreaks

I have decided to decline (indicated above) the vaccination(s) recommended for my child (indicated

above) because the vaccination(s) conflict with my personal religious beliefs. Further, I affirm the truth of

this statement under the penalty of perjury.

I acknowledge I have read this document in its entirety and fully understand it.

_____________________________________

Parent or Guardian

Date

_____________________________________

Witness

Date

__________________________

Notary Public

Date Commission Expires__________________

PH 3810

RDA S 836-1

07/06/04

Physical Examinations & Immunizations

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