Certificate Of Exemption From School/daycare Immunization Requirements Template (Page 2 of 2) in pdf

CERTIFICATE OF EXEMPTION

FROM SCHOOL/DAYCARE IMMUNIZATION REQUIREMENTS

Please Print Clearly, Complete all Fields, Use CAPITAL LETTERS ONLY

Child’s Information

School Name

First Name

School Address

School City

Last Name

Address

School State

School Zip Code

or P.O. Box

City

Child’s Grade

State

Zip Code

Child’s Date of Birth

Phone

Sex

Ethnicity

Race

Hispanic

Male

Native American

Black

Other

Mail original to:

I request that the 9 month period this

Female

Non-Hispanic

Asian

White

NM Immunization Program

exemption form is valid for begin on

1190 St. Francis/ Runnels S-1250

I object to my child receiving the following:

PO Box 26110

Tetanus

Hib - Haemophilus Influenza type B

Hepatitis A

Santa Fe, NM 87502-6110

Diphtheria

Measles

Hepatitis B

Pertussis

Varicella (Chicken Pox)

Mumps

Pneumococcal

Rubella

Polio

Directions

Please complete this form. Check the box that corresponds to your request for exemption. Then in the presence of a Notary Public, please sign and date this

certificate and have it notarized. IT IS THE PARENT/GUARDIAN’S RESPONSIBILITY TO ENSURE AN APPROVED COPY OF THIS EXEMPTION

CERTIFICATE IS FILED WITH THE CHILD’S SCHOOL.

I request exemption from immunization requirements in accordance with:

NMAC 7.5.3.8 A.1, and I am attaching an affidavit or certificate from a duly licensed physician attesting that any of the required immunizations

would seriously endanger the life or health of my child.

NMAC 7.5.3.8 A.2, because I am presenting an affidavit or written affirmation from an officer of my denomination stating we are bona fide members

of a recognized religious denomination which requires reliance on prayer or spiritual means alone for healing.

NMAC 7.5.3.8, and I hereby certify that my religious beliefs, held either individually or jointly with others, do not permit the administration of vaccine or

other immunizing agents.

I UNDERSTAND THIS REQUEST IS SUBJECT TO THE APPROVAL OF THE NEW MEXICO DEPARTMENT OF HEALTH. I HAVE READ THE ‘COMPULSORY

IMMUNIZATION REGULATIONS’ AND UNDERSTAND THE RISK OF NON-IMMUNIZATION FOR MY CHILD. I UNDERSTAND THAT THIS CERTIFICATE,

IF APPROVED, IS VALID FOR A PERIOD NOT TO EXCEED NINE MONTHS AND WILL EXPIRE THEREAFTER. IF I WISH TO REQUEST ANOTHER

EXEMPTION AFTER THE NINE MONTH PERIOD, I MUST COMPLETE ANOTHER CERTIFICATE OF EXEMPTION AND SEEK APPROVAL.

I ALSO UNDERSTAND THAT WHERE ANY CASE OF COMMUNICABLE DISEASE OCCURS OR IS LIKELY TO OCCUR IN MY CHILD’S SCHOOL, THE

DEPARTMENT OF HEALTH MAY REQUIRE THE EXCLUSION OF INFECTED PERSONS AND NON-IMMUNIZED PERSONS (7.4.3.9 NMAC - Rp, 7 NMAC

4.3.9, 8/15/2003).

I swear that all the foregoing statements are true to the best of my information, knowledge and belief.

Notary Seal

Parent/guardian’s name (print clearly) _____________________________________________________

Parent/guardian’s signature: ___________________________________ Date: ____________________

NOTARY

Subscribed and sworn before me this ______________ day of _________________, 20____.

________________________________ My Commission expires:______________________

Notary’s Signature

Date

APPROVED BEGINS ON

DISAPPROVED

DOH Use Only:

m m d d y

y y

____________________________________

Revised July 8, 2013

EXPIRES ON

Date

Authorized Signature

Certificate Of Exemption From School/daycare Immunization Requirements Template Page 2

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