Certificate Of Exemption From School/daycare Immunization Requirements Template printable pdf download

Exemption from Immunization Form

Instructions

Who may use the Exemption from Immunization Form:

Individuals requesting a religious or medical exemption to immunization may use this form.

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This form may be used for all children with an exemption going into any public, private or parochial pre-

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school, kindergarten, elementary, secondary school, or home school and for children attending daycare or

childcare facilities.

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This form may not be used for exemption from immunization for personal or philosophical reasons. New Mexico

law does not allow for such exemption. (Please see New Mexico Law 24-5-3 at page bottom.)

How to Complete the Exemption from Immunization Form:

Fill out all blank lines and check boxes, including the check boxes for the religious or medical options.

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For medical exemptions, attach the letter from your duly licensed physician to this form.

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For religious exemptions using an affidavit, please attach the affidavit to this form.

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The form must be signed by a notary public.

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Mail the form to the New Mexico Department of Health at the address shown on the form. You may also submit

your form in a drop box at the Department of Health in Santa Fe (Runnels Building).

Department of Health Exemption from Immunization Form Processing:

The Department of Health has 60 days from receipt of the Religious Exemption from Immunization Form to

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either approve or not approve the request (see NMAC 7.5.3 below). Make sure that the Department of Health

receives the form at least 60 days prior to the day your child starts school.

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Upon approval, the Department of Health will mail you two copies of the approved form. The Parent/Guardian

must take one copy of the approved form to your child’s pre-school, school, daycare, or childcare facility.

If your request is not approved, you will get a letter from the Department of Health telling you why your request

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was denied. You will also receive information on how to arrange for a meeting with the Department of Health

should you wish to protest.

New Mexico Immunization Exemption Law (24-5-3):

Any minor child through his parent or guardian may file with the health authority charged with the duty of enforcing the

immunization laws:

(1) A certificate of a duly licensed physician stating that the physical condition of the child is such that immunization

would seriously endanger the life or health of the child; or

(2) Affidavits or written affirmation from an officer of a recognized religious denomination that such child’s parents or

guardians are bona fide members of a denomination whose religious teaching requires reliance upon prayer or

spiritual means alone for healing;

(3) Affidavits or written affirmation from his parent or legal guardian that his religious beliefs, held either individually or

jointly with others, do not permit the administration of vaccine or other immunizing agent.

NMAC 7.5.3: “Within sixty (60) days of receipt of a request for exemption from immunization, the director of the public health

division or the designee shall review the request to determine whether the certificate has been duly completed."

Certificate Of Exemption From School/daycare Immunization Requirements Template

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