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