Add Vaccine Exemption

School Year

The School Year and First Date of Attendance for the School Year is Required

School
Year

*

First Date of Attendance
2024 - 2025 School Year

*

Exemption Type

A Physician's Letter Stating the Medical Reason is Required for a Medical Exemption

Exemption
Type
and
Attachment

*

If Exemption Type is Medical, You May Attach a Physician's Letter Stating the Medical Reason here,

Or You May Include the Letter With Your Completed, Signed, and Notarized Form that You Return.

Student Information

The Student Information is Required

Student
Name

* *

Address 1

*

Address 2

State, County
City, ZIP

* * * *

Phone
Number

E-Mail
Address

*

Date of
Birth

*

Gender

A value for Gender is required.

Race(s)

*

Ethnicity

A value for Ethnicity is required.

Parent or Guardian Information

The Parent / Guardian Information is Required for Students Under 18 Years of Age

Copy Student Info

Parent
or
Guardian
Name
and
Address

Phone
Number

E-Mail
Address

*

Childcare or School Information

Required for Childcare/School Students Only

Public /
Private

Type of
School

School
District

** Please Select **

School

** Please Select **

School
Grade

** Please Select **

College or University Information

Required for College/University Students Only. Exemption Available for MMR Only.

College or
University

** Please Select **

Statement of Refusal to Vaccinate

View and Check the Box to Acknowledge the Vaccine Information for the Vaccine(s) that you DO NOT want the Student to Receive

MMR Vaccine Information

Mandatory Vaccine for ALL Students, Including College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the MMR vaccine, the student listed here is at risk of a rash, fever, cough, diarrhea, muscle aches, ear infections, pneumonia, headaches, seizures, meningitis, brain infections, inflammation of the testicles and ovaries, sterility, arthritis, inflammation of the pancreas, permanent deafness, brain damage, and death. Birth defects if acquired while pregnant include deafness, cataracts, heart defects, mental retardation, and liver and spleen damage in the baby.

DTaP Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the DTaP vaccine, the student listed here is at risk of a sore throat, fever, heart complications, feeding problems, paraalysis, whooping cough, respiratory complications, coma, and death.

Hib Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Hib vaccine, the student listed here is at risk of skin and throat infections, ear infections, meningitis, pneumonia, blood infections, arthritis, permanent brain damage, and death.

Hepatitis A Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Hepatitis A vaccine, the student listed here is at risk of yellow skin or eyes, flu-like illness, abdominal pain, loss of appetite, nausea, joint pain, and/or life-long liver problems (such as scarring of the liver and cancer or the need for a liver transplant), and death.

Hepatitis B Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Hepatitis B vaccine, the student listed here is at risk of yellow skin or eyes, flu-like illness, abdominal pain, loss of appetite, nausea, joint pain, and/or life-long liver problems (such as scarring of the liver and cancer or the need for a liver transplant), and death.

Meningococcal Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Meningoccal vaccine, the student listed here is at risk of Meningitis, which is a severe infection of the covering of the brain and the spinal cord. The student is also at risk of blood infections, problems with their nervous system, loss of arms or legs, permanent deafness, suffer from strokes or seizures, and death.

Pneumococcal Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Pneumococcal vaccine, the student listed here is at risk of severe disease including meningitis, which is a severe infection of the covering of the brain and the spinal cord. The student is also at risk of blood infections, pneumonia, permanent deafness, brain damage, and death.

Polio Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Polio vaccine, the student listed here is at risk of a fever, sore throat, nausea, headaches, stomachaches, stiffness, paralysis that can lead to permanent disability, and death.

Td Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Td vaccine, the student listed here is at risk of seizures, serious neuromuscular disease, heart problems, and death.

Tdap Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Tdap vaccine, the student listed here is at risk of pneumonia, whooping cough, seizures, inflammation of the brain, serious neurological complications, and death.

Varicella Vaccine Information

Mandatory Vaccine for Childcare/School Students, NOT College Students

By checking the box below, I am requesting an exemption from this vaccine.

I have read the Vaccine Information Statement and understand by not receiving the Varicella vaccine, the student listed here is at risk of a rash, severe skin infections, scars, pneumonia, seizures, brain infection, and death.

*