Hawaii Vaccination Exemption Form printable pdf download

VACCINATION EXEMPTION PURSUANT TO THE

Hawaii Administrative Rules §11-157-5 & OFFICIAL CODE OF Haw. Rev. Stat. § 325-34

§11-157-5 Exemptions. (b) A religious exemption shall be granted to a student whose parent, custodian, guardian, or

other person in loco parentis certifies that the person’s religious beliefs prohibit the practice of immunization. Requests

for religious exemptions based on objections to specific immunizing agents will not be granted. Students who have

reached the age of majority shall apply on their own behalf. The certification shall be retained in the student’s health

record. Reports of such exemptions shall be submitted to the department by each school.

§ 325-34 No person shall be subjected to vaccination, revaccination or immunization, who shall in writing object thereto

on the grounds that the requirements are not in accordance with the religious tenets of an established church of which the

person is a member or adherent, or, if the person is a minor or under guardianship, whose parent or guardian shall in

writing object thereto on such grounds, but no objection shall be recognized when, in the opinion of the director of health,

there is danger of an epidemic from any communicable disease.

__________________________________________________________________________________________

VACCINE EXEMPTION FORM

I,____________________________, as the parent, guardian or person in

(insert your name)

loco parentis of the child __________________________, hereby certify that the

(insert your child’s name)

administration of any vaccine or other immunizing agents is contrary to our personal

religious beliefs.

□ Diphtheria

□ Measles

□ Other

□ Tetanus

□ Mumps

□ ALL

□ Pertussis

□ Rubella

□ Polio

□ Haemophilus influenzae type b

□ Hepatitis B

□ Varicella

□ Smallpox

□ Anthrax

This is pursuant to my right to refuse vaccination on the grounds that vaccinations conflict with

my religious beliefs. Pursuant to Hawaii statute I am providing a copy of this statement to our

child’s school administrator or operator of the group program pursuant to

Hawaii Administrative Rules §11-157-5 and Haw. Rev. Stat. § 325-34.

Parent __________________________________ Date _______________

Subscribed and Sworn before me this _____ day of ___________, 20____.

________________________________________

Notary's Signature and Seal

Hawaii Vaccination Exemption Form