Form Dch-0716 - Immunization Waiver Form printable pdf download

IMMUNIZATION WAIVER FORM

INSTRUCTIONS TO PARENTS OR GUARDIANS:

Vaccine-preventable diseases are still with us. In many cases, they cause disability or death. Immunizations are one of our most cost-

effective measures to protect children from harmful diseases. A high proportion of children must be immunized to prevent outbreaks of

disease in school settings and other places where children work and play closely together.

Sections 9208 and 9211 of the Michigan Public Health Code require that a parent, guardian, or person in loco parentis applying to have a

child registered for the first time in a Michigan school or in a program of group residence, care, or camping in this state shall present to

officials at the time of registration or not later than the first day of school or program enrollment, a certificate of immunization verifying

that the child has been vaccinated against diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis B, and varicella

(chickenpox). Vaccination for Pneumococcal conjugate is also required for preschool-aged children. The Haemophilus influenza type b

is not required for the 2009-20010 reporting season.

A parent or guardian wishing to exempt his or her child from a particular vaccination must provide a written statement indicating the

religious or philosophical objections to the vaccination(s). A child who has been exempted from a vaccination is considered susceptible

to the disease or diseases for which the vaccination offers protection. The child may be subject to exclusion from the school or program,

if the local and or state public health authority advises exclusion as a disease control measure.

By signing this waiver, you acknowledge that you are placing your child and others at risk of serious illness should he or

she contract a disease that could have been prevented through proper vaccination.

ALL INFORMATION MUST BE FILLED IN BELOW

I object to having my child,

, born

, immunized against the

diseases I have checked below:

(First & Last Name)

(Birth Date)

Diphtheria

Measles

Hepatitis B

Tetanus

Mumps

Haemophilus influenzae type b

Pertussis

Rubella

Pneumococcal Conjugate

Varicella (chickenpox)

Polio

Reason:_____________________________________________________________________________________________________

___________________________________________________________________________________________________________

Parent(s)/Guardian(s) Name:____________________________________________________________________________________

Address:

Telephone:_______________________________________

Child's Address:

Telephone:_______________________________________

If different from parent/guardian

_________________________________________________________________

_____________________

Parent or Guardian's Signature

Date Signed

___________________________________________________________

Preschool Program or Licensed Day Care Center OR School Name (Required)

File in the child's permanent record and send a copy to your local health department.

DCH-0716

AUTHORITY: P.A. 368 of 1978, Part 92

Rev. 5/2009

CAPITOL VIEW BUILDING



201 TOWNSEND STREET



LANSING, MICHIGAN 48913

DCH-1272 (07/05) (W)



(517) 373-3740

Form Dch-0716 - Immunization Waiver Form

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