School Immunization Exemption Form
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1SCHOOL IMMUNIZATION EXEMPTION FORM
Vermont’s School Immunization Regulations apply to any student in attendance at any public or
independent kindergarten, any elementary or secondary school and any post-secondary school,
unless exempt by law. Before school entry, students must have the required immunizations unless
exempted from immunizations for medical, religious, or moral (philosophic) reasons.
Note: Students exempted from required immunizations may face exclusion from school should a
vaccine-preventable disease outbreak occur and the Department of Health determines that such
action is necessary to protect the student and/or the public health.
Complete this section, the appropriate signature portion and submit to your school
___________________________________________
_______/________/_________
Name of Student
Birth Date
Exemption applies to the following vaccines(s):
DTaP/DTP/DT
Td/Tdap
Polio
MMR
Measles
Rubella
Mumps
Hepatitis B
MEDICAL EXEMPTION:
The following vaccine(s) are medically contraindicated:___________________________________
Reason for exemption:____________________________________________________________
This exemption shall continue until __/__/______ _______________________ _____________
Date
Print name of physician
Telephone
_________________________________________________________
____/_____/________
Signature of Physician
Date
RELIGIOUS EXEMPTION:
I request that immunization(s) be waived because they conflict with free exercise of religious rights.
_____________________________________
___________________ ____/___/______
Signature of Parent (or student if 18 yrs or older)
telephone
Date
MORAL (PHILOSOPHIC) EXEMPTION:
I request that immunizations(s) be waived because they conflict with free exercise of moral
(philosophic) rights.
_____________________________________
___________________ ____/___/______
Signature of Parent (or student if 18 yrs or older)
telephone
Date
Vermont Immunization Program 1-800-464-4343 ext. 7638
8/2007
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