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| School Year | | Attendance Date |
| Exemption Type | | Vaccine Exemption |
| Student | Parent | Student Name and Address |
County
| Phone
E-mail
Date of Birth
Gender
Ethnicity
Race(s) |
| Parent Name and Address |
County
| Phone
E-mail |
| | | | | School Type
School District |
| School Level
School
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| 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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