Department Of Defense Education Activity Request For Exemptions From Immunization
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1DEPARTMENT OF DEFENSE EDUCATION ACTIVITY
REQUEST FOR EXEMPTIONS FROM IMMUNIZATION
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. section, 2164 and 20 U.S.C. sections 921-932.
PRINCIPAL PURPOSE(S): This form is completed by child's parent or guardian to claim exemption from immunization requirements.
ROUTINE USE(S): DoDEA may release information without prior consent within the DoD when needed to perform an official DoD duty, in
accordance with 5 U.S.C. section 552a(b)(1). DoDEA also may release information outside the DoD, in accordance with 5 U.S.C. section
552a(b)(2-12), and the “Blanket Routine Uses,” published at Examples of release may include
for valid medical, law enforcement or security purposes, or for use in litigation involving the DoD.
DISCLOSURE: Disclosure to the Agency of the information requested on this form is voluntary; but failure to provide all requested
information may result in the delay or denial of student enrollment or services.
1. NAME
(Last, First, Middle Initial)
2. SCHOOL
3. GRADE
4. PLEASE PROVIDE AN EXPLANATION FOR THE REQUESTED EXEMPTION
(Attach additional page if necessary.)
5. EXCLUSION FROM SCHOOL: I understand that, in the occurrence of an outbreak,
potential epidemic or epidemic of a vaccine-preventable disease in my community/my child's
school, the Local Military Medical Authority may order my child's exclusion from school, for
my child's own protection, until the danger has passed.
a. SIGNATURE OF PARENT/GUARDIAN
b. DATE SIGNED
(MM/DD/YYYY)
PREVIOUS EDITION IS OBSOLETE.
DoDEA FORM 2942.0-M-F4, (SHSG: H-2-1) November 16, 2011
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