Request For Exemption From Vaccination And Immunization

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REQUEST FOR EXEMPTION FROM VACCINATION AND IMMUNIZATION
To: __________________________________________________________________,
Director of the _________________________________________________ School
As a parent/guardian having control of and responsibility for
_________________________________________, a minor enrolled in
the ______________________________________ school, I request
that said minor be exempt from the vaccination and immunization
requirements on religious grounds in accordance with the Indiana
Code 20-8.1-7-9.5 section 2A. I certify that the administration of
vaccine and other immunizing agents to my child _______________
________________________, is contrary to both _____________________
____________________________ and my personal religious beliefs,
held either individually or jointly with others, and I therefore
request that my child be exempt from the immunization
requirements of the Indiana State Statute 9.5.
Parent/Guardian: ____________________________________________
Address: _____________________________________________________
Date: __________________for School Year: _________ - ___________

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