Hepatitis A Immunization Religious Exemption Form - Saint Louis County Doh/cdc printable pdf download

Hepatitis A Immunization Religious Exemption Form - Saint Louis County Doh/cdc

HEPATITIS A IMMUNIZATION

RELIGIOUS EXEMPTION FORM

STATE OF MISSOURI

)

) SS

COUNTY OF ST. LOUIS

)

This is to certify that

____ I

____ (Name of minor) ___________________________, of

whom I am parent or guardian

should be exempted from receiving immunization against Hepatitis A because

of the following religious belief(s):

_____________________________________________________________

Name (Print or type) _____________________________

I certify under penalty of perjury that the above statements are true

and correct to the best of my knowledge.

Subscribed and sworn to before me, a Notary Public, this ______

day of ____________, ______.

______________________________

Notary Public

My commission expires:____________

Return form to:

Saint Louis County DOH/CDC

111 South Meramec

Clayton, MO 63105

Hepatitis A Immunization Religious Exemption Form - Saint Louis County Doh/cdc