Vaccine Exemption Form

Name

First NameLast Name

Age

Date of Birth

Date

Race

Gender

Race

School Name

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Rows	Exemption	Duration	Reason
Diptheria	1
Tetanus	2
Pertussis	3
Polio	4
MMR (Measles, Mums, Rubella)	5
Hepatitis B	6
Varicella (Chickenpox)	7
Meningococcal	8

Kindly check the purpose and contraindication of the vaccine on the table below:

Vaccine Name	Description	Signs and Symptoms
Diptheria	This is caused by bacteria that lead to respiratory or cardiovascular problems.	Difficulty of breathing, shortness of breath, heart failure, or paralysis.
Tetanus	This is a vaccine that prevents tetanus. Tetanus is an infection and its causative agent is Clostridium tetani.	Muscle spasms, swallow difficulties, muscle pain, jaw stiffness, fever, or excessive sweat.
Pertussis	Whooping cough caused by Bordetella pertussis.	Runny nose, fever, coughing
MMR (Measles, Mumps, Rubella)	Prevents measles, mumps, and rubella to individuals.	Fever, itchiness, neck stiffness, muscle spasms, fever
Hepatitis B	It infects body organs like the liver.	Yellow skin coloration, fever, fatigue, weakness, nausea, and vomiting
Varicella (Chickenpox)	Rashes all over the parts of the body.	Fever, loss of appetite, body weakness, itchiness, blisters
Meningococcal	An infection that affects the brain and spinal cord.	Fever, loss of appetite, body weakness, rashes, headache, joint pain, nausea, and vomiting

Please explain in paragraph format why are you requesting for vaccine exemption.

Date Signed

Date

Parent/Guardian Signature

Doctor/Physician Name

First NameLast Name

Date Signed

Date

Doctor/Physician Signature

Health Official Name

First NameLast Name

Date Signed

Date

Health Official Signature

Child Information