Sample Request For Religious Exemption To Immunization Form Page 4

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Request for Religious Exemption to Immunization Form (continued ) Page 4 of 4
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You may attach additional sheets if necessary.
Reviewer Signature (Building Principal) ______________________________________________
● Parent/guardian must be notified in writing of the approval or denial of the request. If the request is denied,
the notification letter must include the specific reason(s) for denial.
● If a religious exemption request is denied, the parent/guardian may appeal the denial to the Commissioner of
Education within thirty (30) days of the decision, pursuant to Education Law, Section 310.
March 2006

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