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Personal Beliefs Arizona Form 2013-2023
Is
submitted to the school. The information below is provided to ensure that parents are informed about the risks of not vaccinating.
Place an “X” in the box to the left of each disease listed to exempt your child from the vaccine. Initial and date the box on the right.
Diphtheria (DTaP, DT, Tdap, Td): I have been informed that by not receiving this vaccine, my child is at
Initials___________
increased risk of developing diphtheria if exposed to this disease. Serious symptoms and effects of...
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