|
| School
Year | | Attendance Date |
| Exemption
Type | | Vaccine
Exemption |
| | Student | Parent | Student
Name
and
Address |
County
| Phone
E-mail
Date of Birth
EvaluateFormula("= \"Sex\"", true)
Ethnicity
Race(s) |
| Parent
Name
and
Address |
County
| Phone
E-mail |
| | | | | School Type
School District |
| School Level
School
|
| School Grade |
| College University | | |
|
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|
|
| | | | MMR Vaccine | | EvaluateFormula("= \"DTaP Vaccine\"", true) | | EvaluateFormula("= \"Hib Vaccine\"", true) | | Hepatitis A Vaccine | | | Hepatitis B Vaccine | | Meningococcal Vaccine | | Pneumococcal Vaccine | | Polio Vaccine | | | EvaluateFormula("= \"Td Vaccine\"", true) | | Tdap Vaccine | | Varicella Vaccine | | | | | You must print the Immunization Exemption Form, then sign, notarize, and return it to the Immunization Program in order to complete your Immunization Exemption. | |
| | After you print, be sure to 'Submit' | |
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