Statement of Immunization History

WAIVER; RULES - INDIANA CODE §20-34-4-5

(a) Each school shall require the parent of a student who has enrolled in the school to furnish not later than the first day of school a written statement of the student's immunization, accompanied by the physician's certificates or other documentation, unless a written statement of this nature is on file with the school.
(b) The statement must show, except for a student to whom IC 20-34-3-2 or IC 20-34-3-3 applies, that the student has been immunized as required under section 2 of this chapter. The statement must include the student's date of birth and
the date of each immunization.

VACCINATION EXEMPTION PURSUANT TO INDIANA CODE §20-34-3-2

(a) Except as otherwise provided, a student may not be required to undergo any testing, examination, immunization, or treatment required under this chapter or IC 20-34-4 when the child's parent objects on religious grounds. A religious objection does not exempt a child from any testing, examination, immunization, or treatment required under this chapter or IC 20-34-4 unless the objection is:
(1) made in writing;
(2) signed by the child's parent; and
(3) delivered to the child's teacher or to the individual who might order a test, an exam, an immunization, or a treatment absent the objection.

This is pursuant to my right to refuse vaccination on the grounds that vaccinations conflict with my religious beliefs. Pursuant to Indiana statute I am providing a copy of this statement to our child's school administrator or operator of the group program pursuant to IC§ 20-34-3-2.

Dear Parent/Guardian:
Your child has a medical/religious exemption to vaccination and is not fully immunized. Although your child remains at risk for getting a vaccine preventable disease, IC 20 -34-4 permits your child to attend school.

In the event of an outbreak of a vaccine preventable disease for which your child is not fully vaccinated, your child may be excluded from school to protect his/her health and the health of all our students and staff. It is important to understand that with some diseases such as measles, one infected child is an outbreak. The length of time your child will be kept out of school depends on the disease. Your child's exclusion may be as long as 3-4 weeks.

If your child is excluded from school, your child will also be excluded from school sponsored activities, such as sporting events, dances, and graduation that occur within the exclusion period. The school will notify you when your child can return to school.

Incompletely vaccinated children can be excluded from school due to cases of measles, chickenpox, pertussis, mumps, or any other vaccine preventable disease (at the discretion of the local health officer).

Acknowledgement of Consequences of Incomplete Vaccination

I understand that my child may be excluded from school in the event of an outbreak of a vaccine preventable disease.

I understand that school exclusion includes after-school activities, such as sporting events, dances, and graduation.

I understand that my child may be required to stay home for multiple weeks during an outbreak of a vaccine preventable disease for which he/she is not vaccinated.

Questions: Jenni Hill, School Nurse jhill@ss-fc.org