Sample Request For Religious Exemption To Immunization Form (Page 3 of 4) in pdf

Sample Request For Religious Exemption To Immunization Form Page 3

Request for Religious Exemption to Immunization Form (continued ) Page 3 of 4

SECTION BELOW FOR SCHOOL DISTRICT USE ONLY

To the Building Principal:

If, after review of the parental statement, questions remain about the existence of a sincerely held religious belief,

Department of Health regulation [10 NYCRR, Section 66-1.3(d)] permits the principal to request supporting

documents. Some examples include:

• A letter from an authorized representative of the church, temple, religious institution, etc. attended by

the parent/guardian, literature from the church, temple, religious institution, etc. explaining

doctrine/beliefs that prohibit immunization (Note: Parents/guardians need not necessarily be a

member of an organized religion or religious institution to obtain a religious exemption);

• Other writings or sources upon which the parent/guardian relied in formulating religious beliefs that

prohibit immunization;

• A copy of any parental/guardian statements to healthcare providers or school district officials in a

district of prior residence explaining the religious basis for refusing immunization;

• Any documents or other information the parent/guardian may be willing to provide that reflect a

sincerely held religious objection to immunization (for example: disclosure of whether

parent/guardian or other children have been immunized, parent/guardian’s current position on

allowing himself or herself or his or her children to receive or refuse other kinds of medical

treatment.)

Reviewer Name (Building Principal) ________________________________________________

Indicate Result of Request Review:

APPROVED

Date of Approval_______________

DENIED

Date of Denial

_______________

State Specifically Reason(s) for Denial

___________________________________________________________________________

_______________________________________

March 2006

Sample Request For Religious Exemption To Immunization Form Page 3