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Add an Immunization Exemption Application
School Year
The School Year and First Date of Attendance for the School Year is Required
School
Year
  First Date of Attendance
   
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  
Race(s)  
Ethnicity  
Parent or Guardian Information
The Parent / Guardian Information is Required for Students Under 18 Years of Age
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
School
School
Grade
College or University Information
Required for College/University Students Only. Exemption Available for MMR Only.
College or
University
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
MyLiteral
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
MyLiteral
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
MyLiteral
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
MyLiteral
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
MyLiteral
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
MyLiteral
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
MyLiteral
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
MyLiteral
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.