Certificate Of Immunization Form - Colorado Department Of Public Health And Environment
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1COLORADO LAW REQUIRES THAT THIS FORM BE COMPLETED FOR EACH SCOUT ATTENDING A COLORADO SCOUT CAMP
Name______________________________________________________________________ Date of Birth_____________________________________
Parent/Guardian_____________________________________________________________ Dates of the Camp Session________________________
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT - CERTIFICATE OF IMMUNIZATION
Vaccine
(Enter the month, day and year each immunization was given.)
Hep B
Hepatitis B
DTaP
Diphtheria, Tetanus, Pertussis (pediatric)
DT
Diphtheria, Tetanus (pediatric)
Tdap
Tetanus, Diphtheria, Pertussis
Td
Tetanus, Diphtheria
Hib
Haemophilus influenzae type b
IPV/OPV
Polio
PCV
Pneumococcal Conjugate
MMR
Measles, Mumps, Rubella
Varicella
Chickenpox
Healthcare Provider
Documentation Date________________________
Lab Verification Date_______________________
STATEMENT OF EXEMPTION TO IMMUNIZATION LAW
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM CAMP AND TO QUARANTINE.
MEDICAL EXEMPTION:
The physical condition of the above named person is such that immunization would endanger life or health or is medically
contraindicated due to other medical conditions.
Medical exemption to the following vaccine(s):
La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s):
Signed _______________________________________ Date _________________
Physician (Medico)
HepB
DTaP
Tdap
Hib
IPV
PCV
MMR
VAR
RELIGIOUS EXEMPTION:
Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed to
immunizations.
Religious exemption to the following vaccine(s):
Exención por motives religiosos de la(s) siguiente(s) vacuna(s):
Signed _______________________________________ Date _________________
Parent, guardian, emancipated Scout/counseling minor
HepB
DTaP
Tdap
Hib
IPV
PCV
MMR
VAR
PERSONAL EXEMPTION:
Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed to
immunizations.
Personal exemption to the following vaccine(s):
Exención por creencias personales de la(s) siguiente(s) vacuna(s):
Signed _______________________________________ Date _________________
Parent, guardian, emancipated Scout/counseling minor
HepB
DTaP
Tdap
Hib
IPV
PCV
MMR
VAR
PARENT/GUARDIAN AUTHORIZATIONS
Parent/Guardian Name__________________________________________
Parent/Guardian Name__________________________________________
Parent/Guardian Address________________________________________
Parent/Guardian Address________________________________________
Parent/Guardian Telephone Day__________________________________
Parent/Guardian Telephone Day__________________________________
Eve_______________________ Cell__________________________
Eve_________________________ Cell________________________
Place of Employment___________________________________________
Place of Employment___________________________________________
Address_____________________________________________________
Address_____________________________________________________
Phone #_____________________________________________________
Phone #_____________________________________________________
Individual authorized to take the Scout from camp if different from the parent or guardian:
Name___________________________________ Address___________________________________ City______________ ST____ Zip______________
Phone # Day___________________________ Eve______________________________ Cell_____________________________
I hereby authorize the above named person to participate in all special trips or excursions in which the Scout may be walking or riding away from the
campsite.
Parent/Guardian/Custodial Adult____________________________________________________________ Date_________________________________
The above named person is restricted from the activities listed below:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Parent/Guardian/Custodial Adult____________________________________________________________ Date_________________________________
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