Refusal To Vaccinate Form
Child Details
Child's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Race
Native American
Asian
Black
White
School Name
School Level
Parent/Guardian Details
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vaccinations
Vaccine
Declined
Reason
Doctor/Nurse Name who recommended
Diptheria
Tetanus
Pertussis
Polio
MMR (Measles, Mumps, Rubella)
Hepatitis B
Varicella (Chickenpox)
Meningococcal
Confirmation
I understand that without a vaccine, the child is susceptible to communicable diseases that can be prevented.
I confirmed that I have been informed that my child might be at risk for the following communicable diseases if the vaccine was not taken.
I acknowledge that medical professionals and health workers about the advantages and disadvantages of not having vaccines.
I understand that the department's health and the government shall not be liable if the child got infected by a communicable disease.
I acknowledge that my child will be excluded from school, gatherings, or any programs if there's an outbreak.
I permit that this document can be shared to any facilities or institutions if needed.
Parent/Guardian Signature
Clear
Date
-
Month
-
Day
Year
Date
Witness/Health Care Worker Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
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