Medical Exemption Request
The child’s pediatrician, family physician or internist licensed in Mississippi must complete and submit this
form to the District Health Officer where the child will be attending school.
The District Health Officer will complete the Medical Exemption Form 122 and return it via mail to the
physician and/or parent at the addresses indicated below.
Date of Request: ____________________
Name of Child: __________________________________________________ Date of Birth: __________________
Name of Parent: _______________________________________________________________________________
Address: ______________________________________________________________________________ _______
Indicate the exemption status for each vaccine in the table below (an exemption status is required for each vaccine):
Mark Permanent, Temporary or No Exemption
Expiration Date if Temporary
*For child care only
grade entry only
Indicate reason for medical exemption (use additional sheets if needed):
Print name of child’s pediatrician/family
physician/Internist licensed in MS:
Telephone Number: ____________________________________________________________________________
I declare that:
The physical condition of this child to be such that the vaccination(s) specified on this form would endanger their
life or health and outweighs the risks of death or disability from the vaccine preventable disease.
I have discussed the benefits and risks of immunizations with the parent/guardian as a condition for exemption.
I have informed the parent/guardian that if any vaccine-preventable diseases for which the child has not been
adequately immunized are occurring in or threatening to occur in the community, the child will, for the safety and
benefit of him/herself and other children, be excluded from daycare/ school until the infectious disease is no
longer present or is no longer a threat to the safety and welfare of the child or other children in the
Signature of child’s pediatrician/family physician/internist licensed in MS: ______________________________________
Mississippi Medical License Number: ______________________________ NPI #: _________________________________
This document should be submitted to the District Health Officer located in the district where the child will be attending
school. A list of District Health Officers can be found at
Form 139 IMM
Mississippi State Department of Health