| Vaccine Exemption Forms Online:
By State or Country
At the present
time, not every state has their forms online. Please report
any broken links or page not found.
If you need
legal assistance in regards to anything pertaining to vaccination
exemptions, vaccine injury, etc., please contact the Vaccine
Exemption Alliance.
Alaska
- http://www.vaclib.org/pdf/ak.pdf
Alabama
- (3) A written objection from the parent or guardian of
a student based on religious tenets and practices shall be submitted
in person by the parent or guardian to the County Health Department
for issuance of a Certificate of Religious Exemption from the
required immunizations or testing. A licensed physician can provide
individual exemption from the required immunizations or testing
on a Certificate of Medical Exemption. The Certificate of Religious
Exemption and the Certificate of Medical Exemption will be on
forms approved by the Alabama Department of Public Health and
will be accepted in lieu of the Certificate of Immunization.
Authority:
Code of Alabama, 1975, Section 16-30-5, et. seq.
Author:
Donald E. Williamson, M.D.; Charles H. Woernle, M.D., M.P.H.
History:
October 1, 1982; Amendment June 11, 1993; Amended: Filed
1/17/97,
Effective 2/21/97.
Arizona
- Request for Exemption to Immunization - School (English)
http://www.kyrene.org/health/forms_book/
requestimmexept_schools.pdf
Request
for Exemption to Immunization - School (Spanish)
http://www.kyrene.org/health/forms_book/
RequestSpanExempImmunSchls.pdf
Request
for Exemption to Immunization - Child Care (English)
http://www.kyrene.org/health/forms_book/
RequestExemptImmunChildCare.pdf
Request
for Exemption to Immunization - Child Care (Spanish)
http://www.kyrene.org/health/forms_book/
RequestSpanExemptImmunChildCare.pdf
Schools
have on file a form to be filled in by parent/guardian to refuse
vaccines on philosophical grounds. Exact info here:
http://www.azavenue.com/kelly/Arizona%20
Rules%20and%20Regulations.htm
15-872
. Proof of immunization; noncompliance; notice to parents; civil
immunity
Exemption
information and form
A.
The director of the department of health services, in consultation
with the superintendent of public instruction, shall develop by
rule standards for documentary proof.
B.
A pupil shall not be allowed to attend school without submitting
documentary proof to the school administrator unless the pupil
is exempted from immunization.
Australia
- "The exemption may be religious, medical or conscientious
objection. To claim these objections requires a form to be signed
by your GP stating that s/he has 'counselled' you on the risks
of not vaccinating. This form can be obtained from Medicare or
Centrelink offices. "
Austrialia
conscientious exemption form in pdf format
http://www.hic.gov.au/CA256976001D0618/Lookup
/PDF_GENERAL_ACIR/$file/cfrm_acir_objection.pdf
Medical
Objection link
http://www.hic.gov.au/CA256976001D0618/Lookup/
PDF_GENERAL_ACIR/$file/cfrm_acir_contraindication.pdf
The
forms above can be found at:
http://www.hic.gov.au/yourhealth/forms/index.htm
Canada - Immunization Exemptions
http://www.vaclib.org/exempt/canada.htm
Canada - Exemption information and form
http://www.attached-mom.com/vaccanada.asp
Statement
of Exemption the official Ontario Canada form here. Page 2 is
in French.
Link
to PDF exemption file
http://www.gov.on.ca/MOH/english/forms/pdf/7470-64_.pdf
California
- http://www.gval.com/legal.htm
(California Health and Safety Code Section 120365). This is
the "personal beliefs" exemption in California law.
The
exemption is fairly easy to exercise. Each student in California
is required to submit a "California School Immunization Record"
to be admitted to school (California Health and Safety Code Section
12-375).
On
the reverse of the form is the following statement: "I hereby
request exemption of the child, named in the front, from the immunization
requirements for school/child care center entry because these
immunizations are contrary to my beliefs. I understand that in
case of an outbreak of any of these diseases, the child may be
temporarily excluded from school for his/her protection."
To exercise the exemption, you simply sign the immunization record
under this statement.
There
is another exemption which is available, although it is more difficult
to exercise because a medical opinion is necessary. If immunization
is "contraindicated", that is, considered to be potentially
harmful to the child for medical reasons, an exemption is granted
upon the filing with of "a written statement by a licensed
physician to the effect that the physical condition of the child
is such, or medical circumstances relating to the child are such,
that immunization is not considered safe, indicating the specific
nature and probable duration of the medical condition or circumstances
that contraindicate immunization..." (California Health and
Safety Code Section 120370).
Colorado
- http://www.cdphe.state.co.us/ps/mch/imm/immhom.asp
Section
15 Colorado Rules, Regulations and Laws
2001
Form
1997
Form
A.
Medical exemption - By submitting to the student's school a Certificate
of Immunization with the statement of medical exemption signed
by a physician licensed to practice medicine or osteopathic medicine
in any state or territory of the United States indicating that
the physical condition of the student is such that immunizations
would endanger his/her life or health or is medically contraindicated
due to other medical conditions.
B.
Religious exemption - By submitting to the student's school a
Certificate of Immunization with the statement of religious exemption
signed by the parent(s), or the emancipated student, indicating
that the parent(s), or emancipated student is an adherent to a
religious belief whose teachings are opposed to immunizations.
C.
Personal belief exemption - By submitting to the student's school
a Certificate of Immunization with the statement of personal exemption
signed by the parent(s), or the emancipated student, indicating
that the parent(s), or emancipated student has a personal belief
that is opposed to immunizations.
D.
In the event of an outbreak of disease against which immunization
is required, no exemption or exception from immunization shall
be recognized and exempted persons may be subject to exclusion
from school and quarantine.
State
Requirements ...says to state exemption on reverse side of Immunization
Certificate.
Colorado
Vaccination & Immunization Laws & Exemptions
Connecticut
- http://www.vaclib.org/pdf/ct.pdf
Florida
- Florida fl.pdf file
38k Florida's HRS Form 681. Page 9 of the document is what
is printed out on blue paper and signed by HRS caseworker.
Florida
Case History on Religious Exemption
Sample
Exemption letter for Florida to turn in to Health Dept to get
the DH Blue Form #681
http://www.know-vaccines.org/exemption.html
Georgia
- No official state form. A written exemption which must be notarized
Iowa
- To order an Iowa religious exemption form or other forms
http://www.idph.state.ia.us/common/pdf/
immunization/literature_order_form.pdf
One
helpful source of information is: Network of Iowa Christian Home
Educators (NICHE) found at http://www.the-niche.org/index.html
Iowa
4 H Club Center
Waiver
for persons (youth or adult) Requesting Exemption from Medical
Examinations or treatment.
http://www.extension.iastate.edu/4hcenter/CampMedicalWaiver.PDF
Iowa
administrative code in pdf format
http://www.idph.state.ia.us/common/pdf/
immunization/iowas_imm_code_ch7_641.pdf
Idaho
- Exemption Forms Idaho
- Text file Idaho
- .doc file
Immunization
Certificate of Exemptions from Boise, Idaho schools.
This
is a Spanish Form: PDF exemption file
Serbo
Croatian: Link to PDF exemption file
Farsi
language: Link to PDF exemption file
Illinois
- Illinois: write to IDPH (or HRS) for their exemption forms.
Can also be a written form.
(Illinois
Dept of Public Health or Human Resource Services)
Indiana
- Indiana: below is posted what one parent did for religious exemption...
The
number in Indiana Code is 20-8.1-7-9.5 section 2a for the religious
exemption.
I
[a parent] wrote up & notarized my own using the code #'s
saying ---
In
accordance with Indiana Code # .......I certify that the administration
of vaccine & other immunizing agents to my child,----------,is
contrary to both ------------- & my personal religious beliefs,held
either individually or jointly with others, and I therefore request
that my child be exempt from the immunization requirements of
the Indiana State Statute 9.5.
Kansas
- Kansas requirements, religious exemption allowed:
Immunization
information and KCI forms are available at schools, at most health
care providers and at the Wichita-Sedgwick County Department of
Community Health, 1900 E. 9th, Wichita, KS 67214, or call 268-8441.
Kansas
Certificate of Immunization (KCI Form)
http://www.kdhe.state.ks.us/bcclr/forms/
CCL.007%20Exemption%20from%20Immunization%208-2002.pdf
Kansas
Certificate of Immunization (KCI Form) Form B Medical Exemption
http://www.kdhe.state.ks.us/immunize/download/kci_form_b.pdf
Kentucky
- 3) A local health department, physician, or other licensed
health facility administering immunizations may obtain the following
immunization certificates from the Cabinet for Health Services:
(a)
"Commonwealth of Kentucky Immunization Certificate";
(b)
"Commonwealth of Kentucky Certificate of Medical Exemption";
(c)
"Commonwealth of Kentucky Childhood Immunization Law Certificate
of Religious Exemption"; or
(d)
"Commonwealth of Kentucky Provisional Immunization Certificate".
-----------------------------------------------------------------------------
Section 5. Incorporation by Reference. (1) The following material
is incorporated by reference:
(a)
"Commonwealth of Kentucky Immunization Certificate (EPID
230), revised 9/2002";
(b)
"Commonwealth of Kentucky Provisional Immunization Certificate
(EPID 230A), revised 9/2002";
(c)
"Commonwealth of Kentucky Certificate of Medical Exemption
(EPID 230B), revised 9/2002"; and
(d)
"Commonwealth of Kentucky Childhood Immunization Law Certificate
of Religious Exemption (EPID 230C), revised 9/2002".
http://www.lrc.state.ky.us/kar/902/002/060.htm
214.036
Exceptions to testing or immunization requirement.
Nothing
contained in KRS 158.035, 214.010, 214.020, 214.032 to 214.036,
and 214.990 shall be construed to require the testing for tuberculosis
or the immunization of any child at a time when, in the written
opinion of his attending physician, such testing or immunization
would be injurious to the child's health. Nor shall KRS 158.035,
214.010, 214.020, 214.032 to 214.036, and 214.990 be construed
to require the immunization of any child whose parents are opposed
to medical immunization against disease, and who object by a written
sworn statement to the immunization of such child on religious
grounds. Provided, however, that in the event of an epidemic in
a given area, the Cabinet for Health Services may, by emergency
regulation, require the immunization of all persons within the
area of epidemic, against the disease responsible for such epidemic.
Effective: July 15, 1998 History: Amended 1998 Ky. Acts ch. 426,
sec. 396, effective July 15, 1998. -- Amended 1980 Ky. Acts ch.
55, sec. 1, effective July 15, 1980. -- Amended 1976 Ky. Acts
ch. 128, sec. 4. -- Amended 1974 Ky. Acts ch. 74, Art. VI, sec.
107(3). -- Amended 1968 Ky. Acts ch. 87, sec. 4. -- Created 1962
Ky. Acts ch. 95, sec. 4.
Maine
- Here's a link to the Maine exemption letter form. It is apparently
printed out on a school letterhead. http://www.state.me.us/education/sh/exemption%20form.doc
Maryland
- Description : Maryland DHMH 896 (Sign & date religious
objection or get medical doctor to sign medical contradiction.
Religious exemption checked and signed at the bottom of page one.
Revised 04/01 http://www.howard.k12.md.us/healthserv/DHMH896.pdf
Massachusetts
- Immunization Exemptions and Vaccine Preventable Disease Exclusion
Guidelines in School Settings May 2003
Definition
of Allowable Exemptions There are two situations in which children
who are not appropriately immunized may be admitted to school:
1)
a medical exemption is allowed if a physician submits documentation
that an immunization is medically contraindicated; and
2)
a religious exemption is allowed if a parent or guardian submits
a written statement that immunizations conflict with their sincere
religious beliefs.
Philosophical
exemptions are not allowed by law in Massachusetts, even if signed
by a physician. Only medical and religious exemptions are acceptable.
These exemptions must be kept in the students files at school
(105 CMR 220.000 and M.G.L. c.76, ss. 15 and 15C).
Source:
http://www.geocities.com/HotSprings/Villa/3120/mass.htm
Michigan
- Immunization
Waiver Form
Religious,
personal or Medical exemption.
Source:
Michigan Opposing Mandatory Vaccines:
P.O.
Box 1121, Troy, MI 48099-1121
Phone:
(810) 447-2418.
Minnesota
- PUPIL HEALTH IMMUNIZATION RECORD
http://www.health.state.mn.us/divs/dpc/adps/forms/pupilrec.pdf
Has
provision for both medical exemption and "Conscientious exemption:
No
student is required to have an immunization which is contrary
to the conscientiously held beliefs of his/her parent or guardian.
To receive this exemption,a parent or legal guardian must complete
and sign the following statement and have it notarized."
Exemption
information and form This is an online form that one can copy
and paste from the html
http://www.duluth.k12.mn.us/nurses/exemption.html
Mississippi
- Write to state for:
Certificate
of Medical Exemption (Form 122) ~~~ Children
Certificate
of Medical Exemption (Form 132) ~~~ Adults
Missouri
- Rules of Department of Health in PDF format:
http://mosl.sos.state.mo.us/csr/19csr/19c20-28a.pdf
PDF
file of the form ordering instructions.
http://www.dhss.state.mo.us/warehouse/580-039.pdf
HTML
file of the form ordering instructions:
http://www.dhss.state.mo.us/warehouse/e-f-vptde.html
ontana - 20-5-405.
Medical or religious exemption.
(1)
When a parent, guardian, or adult who has the responsibility for
the care and custody of a minor seeking to attend school or the
person seeking to attend school, if an adult, signs and files
with the governing authority, prior to the commencement of attendance
each school year, a notarized affidavit on a form prescribed by
the department stating that immunization is contrary to the religious
tenets and practices of the signer, immunization of the person
seeking to attend the school may not be required prior to attendance
at the school. The statement must be maintained as part of the
person's immunization records. A person who falsely claims a religious
exemption is subject to the penalty for false swearing provided
in 45-7-202.
Religious
Exemption Form for school:
Gallatin
Gateway School in Southwest Montana Religious exemption affidavit
form. Can be used throughout the state for other schools. (Updated
in 2000)
http://www.gallatingatewayschool.com/media/
pdf/forms/ReligiousExemptForm.pdf
Montana
Law & links Re exemptions: http://www.ShotFreeInMontana.com
North Carolina
- immunization pursuant to section 15-873.
Medical exemption
statement for North Carolina. http://www.immunizenc.org/images/3987
%20medical%20exemption%208-02.pdf
North Dakota
- Certificate of Immunization
http://www.health.state.nd.us/disease/immune/cofimm.pdf
Check
off religious, moral, personal, etc...must get original from health
dept as there are carbon copies. Top white copy is turned in to
school. Parent keeps yellow copy.
Nebraska
-
http://www.ops.org/scs/hs/Public/Immunization.Waiver.pdf
Would
be good to print the statute on the back of the page.
Nebraska
Neb. Rev. Stat. § 79-221 (2)
Immunization
shall not be required for a student's enrollment in any school
in this state if he or she submits to the admitting official either
of the following:
An
affidavit signed by the student or, if he or she is a minor, by
a legally authorized representative of the student, stating that
the immunization conflicts with the tenets and practice of a recognized
religious denomination of which the student is an adherent or
member or that immunization conflicts with the personal and sincerely
followed religious beliefs of the student.
Nebraska
Administrative Code
www.sos.state.ne.us/local/regsearch/Rules/
Health_and_Human_Services_System/Title-173/Chapter-3.pdf
New Hampshire
-
TITLE
X
PUBLIC
HEALTH
CHAPTER
141-C
COMMUNICABLE
DISEASE
Section
141-C:20-c
141-C:20-c Exemptions. – A child shall be exempt from immunization
if:
I. A physician licensed under RSA 329, or a physician exempted
under RSA 329:21, III, certifies that immunization against a particular
disease may be detrimental to the child's health. The exemption
shall exist only for the length of time, in the opinion of the
physician, such immunization would be detrimental to the child.
An exemption from immunization for one disease shall not affect
other required immunizations.
II. A parent or legal guardian objects to immunization because
of religious beliefs. The parent or legal guardian shall sign
a notarized form stating that the child has not been immunized
because of religious beliefs.
Source.
1987, 193:7, eff. Jan. 1, 1988. 2001, 18:1, eff. Jan. 1, 2002.
http://www.gencourt.state.nh.us/rsa/html/X/141-C/141-C-20-c.htm
The
notarized form for religious exemptions is supplied by the school.
New Jersey
- No official state form. A written exemption. May be a good idea
to notarize.
See
22 page exemption letter, either HTML or .PDF file.
New
Jersey school - New Jersey Children's Center at Bankers Trust
(Harborside)
http://www.childrenfirst.com/parents/mf_nj.PDF
The
exemption is on page 4. This is their own exemption.
New Mexico
- Parents have the right to refuse immunizations for medical,
religious, or
philosophical
reasons. Medical exemptions must be signed by the child's physician
on
letterhead paper and a copy sent to the NM Immunization Program.
Religious/
philosophical exemption forms must be filled out, officially notarized,
and
returned
to the NM Immunization Program for filing. A copy will be given
to
the
parent or guardian to present to the school/daycare. Immunization
exemption
forms
must be renewed and resubmitted every school year.
Download
here:
http://www.health.state.nm.us/Preview/Immunize/
NMID/Pages/Public/sched/COform.pdf
Completed
medical or CO exemption forms must be returned to the Immunization
Program
either by:
1)
Mail:
Celina
Lopez
Attn:
Immunization Exemption Form Immunization Program
NM
Department of Health
1190
St. Francis Dr.
Santa
Fe, NM 87505
2)
Fax: 505-827-1741 or
3)
Or electronically (scanned and emailed): clopez@doh.state.nm.us
New York
- One answer we received is this:
As
far as a religious exemption goes... In NYS there is not have
form to fill out per se...The individual filing must submit a
letter to the appropriate school official stating that they hold
sincere and genuine religious beliefs that contraindicate vaccinations.
See
http://www.vaclib.org/exempt/newyork.htm#letters
New Zealand
- New Zealand does not have compulsory vaccination or financial
penalties for non-vaccinators (yet). They do require a vaccination
certificate on entry into childcare or school. This is to identify
non-vaccinated children during a disease outbreak. Details of
the policy can be found in this Press Release.
http://vaxchoice.crosswinds.net/vaccination/exemption.html
Ohio
- This one is listed for Defiance City, but it cites Ohio state
code in the
document,
and would be accepted for all Ohio schools.
http://www.neola.com/defiancecity-oh/forms/fm5320F1.pdf
Oklahoma
- Medical, Religious, and Personal Exemptions Allowed. You
can pick up a copy of ODH Form 216-A Certificate of Exemption
at your local Health Department or Board of Education. Or
you can print it out here:
http://www.unhinderedliving.com/exemptionform.html
I obtained
this copy of the exemption form from my local board of education.
The original has a white top copy and a yellow second copy.
One copy is for the school, and the other copy is to be sent to
the state health department. When I obtained this from the
local school board, they were out of originals and were just making
xerox copies to hand out. I asked if I could have more copies
to give to my vaccine awareness group, and they said to just make
more xerox copies myself. There is no copyright on the form.
Each person needs two copies to send in, and one copy to keep
for themselves if they want. As far as I know, the Oklahoma
Health Department does not have this form online anywhere.
Oregon
- If you want a great letter written by a lawyer to an Oregon
School Board
http://www.childscreen.org/Letter%20to%
20the%20Oregon%20School%20District.htm
Pennsylvania
- Medical and Religious exemptions allowed.
Download
the form here: http://www.unhinderedliving.com/Vaccine.jpg
South Carolina
- http://www.geocities.com/HotSprings/
Villa/3120/south_carolina.htm
(D)
A South Carolina Certificate of Special Exemption signed by the
school principal, authorized representative, or day care director
may be issued to transfer students while awaiting arrival of medical
records from their former area of residence or to other students
who have been unable to secure immunizations or documentation
of immunizations already received. A South Carolina Certificate
of Special Exemption may be issued only once and is valid for
only thirty calendar days from date of enrollment. At the expiration
of this special exemption, the student must present a valid South
Carolina Certificate of Immunization, a valid South Carolina Certificate
of Medical Exemption, or a valid South Carolina Certificate of
Religious Exemption.
Tennessee
- Write to State for: Tennessee: TCA 49-6-5001(b)(2) ~~~ it's
a green form
Texas
- El Paso Independent School district's s religious exemption
form for download.
http://www.episd.org/Schools/healthservices/immaffrelpg1.pdf
As
of September 1, 2003, Texas is implimenting an exemption to include
anybody who wants to use it "for reasons of conscience, including
religious beliefs."
For
more information see: http://www.vaccineinfo.net/harassment/report.pdf
Utah
- Description : Utah School Immunization Record (If a religious
exemption is claimed, a Religious Exemption Form must be completed
& signed by the parent. The Religious Exemption Form is obtained
from local health dept. A local health dept. rep. must witness
& sign the Religious Exemption Form giving the WHITE &
YELLOW copies to the parent. The parent will present WHITE copy
to school or daycare official. WHITE copy must be attached to
record. PINK copy remains w/health dept. YELLOW copy remains w/parent
Virginia
- This waiver form goes with the official Virginia Form CRE-1
which has to be turned in. The Form CRE-1 has to be notarized
by a notary and also some universities also require signature
from clergy. Clergy can either sign the same form or just write
the exemptions themselves, or they could possibility sign Dr.
Horowitz's waiver form under the parents signature. Good idea
to cover all bases.
PDF
file of form CRE-1 Text
file MS
.doc ver7.0
Virginia
Meningococcal Vaccine Waiver Form
.PDF file
Washington
-
Washington
State .pdf file 35k
Washington
State .pdf file in Spanish [cis99spn.pdf]
Washington
State Vaccine Form & Exemption (French) 19cisfren.pdf 25k
Washington
State ADDITIONAL LANGUAGE FORMS AVAILABLE:
Certificate
of Immunization Status Forms:
Statement
of Exemptions are on back of forms.
Check
and sign, and you have the exemption!
These
came off of this website below....
http://www.doh.wa.gov/cfh/immunize/formpubs.htm#CIS
West Virginia
- Only medical exemptions currently allowed. See the
website
of West Virginians for Vaccine
Exemptions
Wyoming
- Religious and Medical exemptions allowed as of February, 2003.
Contact
the following for a copy of the exemption form:
Wyoming
Department of Health
Web
site http://wdhfs.state.wy.us/WDH/
e-mail
wdh@state.wy.us
Brent
D. Sherard, M.D., Interim Director and State Health Officer
117
Hathaway Building
Cheyenne,
WY 82002
Wyoming
Vaccination Liberation Home page -
http://www.vaclib.org/chapter/wyhome.htm
Interesting
Wyoming court case
IN
THE SUPREME COURT, STATE OF WYOMING, reversal of denial of medical
exemption.
courts.state.wy.us/2001opn/2001WY28.pdf
www.unhinderedliving.com/statevaccexemp.html
Reference Source: http://www.fourwinds10.com/siterun_data/health/vaccinations/news.php?q=1254944893
October 8, 2009
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