Immunization Non-Medical Exemption Form - Religious And Personal Belief

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Immunization
Non-Medical Exemption Form
(Religious and Personal Belief)
Vaccines are one of the greatest public health achievements of the past century and save an estimated 3 million children's lives
every year. The Colorado Department of Public Health and Environment strongly supports vaccination as one of the easiest and most
effective tools in preventing diseases that can cause serious illness and even death. For nearly all children, the benefits of
preventing disease with a vaccine far outweigh the risks. Declining to follow the advice of a health care provider, or public health
official who has recommended vaccines may endanger an unvaccinated child’s health and others who come into contact with
him/her. Some vaccine-preventable diseases are common in other countries and unvaccinated children could easily get one of these
diseases while traveling or from a traveler.
Colorado law C.R.S. § 25-4-902 requires all students attending any school in the state of Colorado to be vaccinated against certain
vaccine-preventable diseases as established by Colorado Board of Health rule 6 CCR 1009-2, unless an official exemption form is
filed. This law applies to students attending child care facilities licensed by the Colorado Department of Human Services, public,
th
private and parochial kindergarten, elementary and secondary schools through 12
grade, and colleges or universities. Prior to
kindergarten, an official non-medical exemption form must be filed each time a student is due for vaccines according to the
1,2
th
schedule developed by the Advisory Committee on Immunization Practices.
From kindergarten through 12
grade, an official non-
1
Students with an
medical exemption form must be filed every year during the student’s school enrollment/registration process
.
exemption may be kept out of child care or school during a disease outbreak.
Please complete all required fields below; incomplete forms will not be accepted. All fields are required unless noted optional.
Type of Non-Medical Exemption Claimed:
□ Personal Belief
□ Religious
Student Information:
Last Name:
First Name:
Middle Name:
(optional)
Gender: □ Female
□ Male
Date of Birth:
Street #:
Street Name:
Street Type
(e.g. Ave.):
Unit #:
P.O. Box:
City:
State: CO
Zip Code:
Email Address:
County:
Phone Number:
□ Home
□ Cell
Parent/Guardian Completing This Form:
□ Check if an emancipated student or student over 18 years old
Last Name:
First Name:
Middle Name:
(optional)
Relationship to student: □ Mother
□ Father
□ Guardian
Street #:
Street Name:
Street Type
(e.g. Ave.):
Unit #:
P.O. Box:
City:
State: CO
Zip Code:
Email Address:
County:
Phone Number:
□ Home
□ Cell
School/Licensed Child Care Facility Information:
School Name/Licensed Child Care Facility:
School District:
Check if Not Applicable
Address:
City:
State: CO
Zip Code:
Phone Number:
Grade of Student:
1
Colorado Board of Health rule 6 CCR 1009-2:
2
2016 Recommended Immunizations from Birth through 6 Years Old: Based on this schedule, a non-
medical exemption form would be submitted at 2 months, 4 months, 6 months, 12 months and 18 months of age.
Immunization Non-Medical Exemption Form. August 2016
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