School Immunization Exemption Form
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1School Immunization
Exemption Form
Vermont’s School Immunization Regulations apply to any students in attendance at any public or
independent kindergarten, any elementary or secondary school and certain post-secondary schools.
Before school entry, students must have the required immunizations unless exempt for medical,
religious, or moral (philosophic) reasons. In order to claim an exemption this form needs to be
completed, signed and returned to the school.
Please note that students who claim an exemption may be kept out of school during the course of a
disease outbreak. The reason for this is that such students will be at high risk for getting that disease
and in-turn transmitting it to other students. The length of time a student is kept out of school will vary
depending on the type of disease and the circumstances surrounding the outbreak. This may be from
as little as several days to over a month.
This document is being submitted on behalf of the following student:
Name:
Date of Birth:
___________________________________ ___________________________ _______/________/_________
Last
First
MEDICAL EXEMPTION
The following vaccine(s) are medically contraindicated:
DTaP/DTP
Td/Tdap
Polio
Hepatitis B
Varicella
Measles
Mumps
Rubella
Meningococcal
_______________________________________________________
Reason for exemption(s):
T his exemption shall continue until : _____/_____/__________
_________________________________________________________________ (_____)_________________
Print Name of Physician
Telephone
_____________________________________________________________________
____/____/_________
Signature of Physician
Date
MORAL (PHILOSOPHIC) EXEMPTION
RELIGIOUS EXEMPTION
I request that following immunization(s) be waived because they conflict with free exercise of
religious rights and /or moral (philosophic) rights:
DTaP/DTP
Td/Tdap
Polio
Hepatitis B
Varicella
Measles
Mumps
Rubella
Meningococcal
_________________________________________________ (______)________________ ____/___/______
Signature of Parent (or student if 18 yrs or older)
Telephone
Date
The Vermont Department of Health
802-863-7638 or
Immunization Program
1-800-464-4343 ext. 7638
108 Cherry Street
healthvermont.gov
Burlington, Vermont 05401
School Immunization Exemption Form 2.8.2008
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