Statement Of Exemption From Immunizations printable pdf download

Statement Of Exemption From Immunizations

STATEMENT OF EXEMPTION FROM IMMUNIZATIONS

Under the Louisiana Revised Statutes 17:170 Sec E, I _________________________________,

parent/guardian of _____________________________________, hereby claim exemption

from the immunization requirements for my child due to medical, religious, or philosophical

reasons.

I understand that in the event of an outbreak of a vaccine-preventable disease at the

location of the educational institution or facility the student attends, the administrators of

the educational institution or facility, upon the recommendation of the office of public

health, may exclude the student from attendance until the incubation period has expired or I

present evidence of immunization.

_____________________________________________________________________________

Name of School

_____________________________________________________________________________

Signature of Parent/Guardian

Date

_____________________________________________________________________________

Signature of Authorized District or School Representative

Date

Statement Of Exemption From Immunizations