Acknowledgement of Religious Exemption to Immunizations Form
This form allows parents or guardians to request a religious exemption from mandatory immunizations for their child or children. It details the risks associated with not immunizing and the conditions under which exempted children may be excluded from school. It requires signatures from both parents and school officials.
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How do I fill this out?
To fill out this form, you will need to provide information about your child, as well as statements from both parents or guardians. You will also need a signature from a school official. Make sure all sections are completed before submission.
How to fill out the Acknowledgement of Religious Exemption to Immunizations Form?
1
Enter the child’s name.
2
Parents or guardians sign the form.
3
School official provides their name and signature.
4
Include the date in all required sections.
5
Submit the completed form to the appropriate school or child care center.
Who needs the Acknowledgement of Religious Exemption to Immunizations Form?
1
Parents who seek a religious exemption from immunizations for their child/children.
2
Guardians responsible for children in preschools or child care centers.
3
School officials verifying the exemption request.
4
Healthcare professionals managing immunization records.
5
Administrators of child care centers ensuring compliance.
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What are the instructions for submitting this form?
Submit this form to your child's school or child care center. You can deliver it in person, email it, or fax it. Ensure to contact the specific institution for their preferred submission method. Always keep a copy for your records. If submitting via email or fax, follow up with a phone call to confirm receipt. Make sure to submit before the school year starts to prevent any delays in your child's attendance.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form before the start of the school year in September 2024 and 2025 to avoid delays.
What is the purpose of this form?
The purpose of this form is to allow parents or guardians to request an exemption from mandatory immunizations for their child or children on religious grounds. It is a legal document that must be completed accurately and submitted to the child's school or child care center. The form also informs parents of the risks associated with not immunizing their children and the circumstances under which the exempted children may be excluded from school or child care during an outbreak.
Tell me about this form and its components and fields line-by-line.
- 1. Child's Name: Enter the full name of the child for whom the exemption is being requested.
- 2. Signature(s) of Parent(s)/Guardian(s): Both parents or guardians need to sign this section to request the exemption.
- 3. Name of School Official: The school official who reviews the form must provide their name.
- 4. Signature of School Official: The school official must sign to validate the exemption request.
- 5. Date: The date when each signer completes their respective sections.
What happens if I fail to submit this form?
Failing to submit this form could result in your child being required to receive mandatory immunizations.
- Mandatory Immunizations: Your child may be required to receive mandatory immunizations if the form is not submitted.
- Exclusion from School: Your child could be excluded from school or child care during a vaccine-preventable disease outbreak.
- Non-Compliance Penalties: You may face penalties for not complying with immunization regulations.
How do I know when to use this form?
- 1. Religious Beliefs: If immunizations interfere with your religious beliefs.
- 2. School Enrollment: When enrolling your child in a new school or child care center.
- 3. Immunization Records: To update your child's immunization records with the exemption.
- 4. Outbreak Situations: During a vaccine-preventable disease outbreak.
- 5. Annual Renewals: When renewing the exemption for the new school year.
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