Waiver for Immunizations

To claim an exclusion for reasons of conscience, including a religious belief, the child's parent, legal guardian, or a student 18 years of age or older must present to the school or child-care facility a completed, signed and notarized affidavit on a form provided by the department stating that the child's parent, legal guardian, or the student declines vaccinations for reasons of conscience, including because of the person's religious beliefs.

The form must be submitted to the school or child-care facility within 90 days from the date it is notarized. The affidavit will be valid for a two-year period from the date of notarization. A child or student who has not received the required immunizations for reasons of conscience, including religious beliefs, may be excluded from school in times of emergency or epidemic declared by the commissioner of the department.


Immunization waiver request.doc