Immunization Waiver Form

IMMUNIZATION WAIVER FORM

Use this form to request a waiver from one or more required immunizations. Complete all applicable fields and sign the certification. Submission of this form does not guarantee acceptance; the facility, school, or program retains authority to accept or deny the waiver in accordance with applicable rules. By signing, the Applicant acknowledges the risks and conditions stated below.

WHEREAS

WHEREAS, immunizations are generally required by certain institutions for the protection of public health; and

WHEREAS, the Applicant seeks an exemption or waiver from one or more immunizations based upon medical contraindication, sincerely held religious belief, or philosophical reason; and

WHEREAS, the facility, school, or program may impose conditions on the waiver, including temporary exclusion during outbreaks or other public health actions.

APPLICANT / PATIENT INFORMATION

Date of Birth:

IMMUNIZATION(S) TO BE WAIVED

Select each immunization from which a waiver is requested:

MMR (Measles, Mumps, Rubella)

Varicella (Chickenpox)

Hepatitis B

DTaP / Tdap

Polio

Influenza (Seasonal)

COVID-19

BASIS FOR WAIVER

Indicate the legal basis for the requested waiver (select one):

Medical contraindication (medical certification required below)

Sincerely held religious belief

Philosophical or personal belief

MEDICAL PROVIDER CERTIFICATION (FOR MEDICAL EXEMPTIONS)

If the medical contraindication box is selected, a licensed medical provider must complete and sign this section. The provider must state the specific contraindication and anticipated duration.

Provider Printed Name:

Provider Signature:

Date Signed:

ACKNOWLEDGMENTS, ASSUMPTION OF RISK AND RELEASE

I, the undersigned, acknowledge that I have been informed of the benefits of the immunizations listed above and that by declining or requesting an exemption I may increase my or the patient's risk of contracting or transmitting vaccine-preventable diseases. I understand that, if an outbreak or exposure occurs, the facility, school, or program may exclude me or the patient from attendance or participation for a period deemed necessary to protect public health.

I certify that the information provided on this form is true and complete to the best of my knowledge. I accept responsibility for any medical or other consequences resulting from the decision to decline or defer immunizations, and I agree to indemnify and hold harmless the facility, school, program, and its employees and agents from claims arising from this waiver, except to the extent caused by their negligence or willful misconduct.

Start Date:    End Date (if temporary):

GOVERNING LAW; ENTIRE AGREEMENT

This waiver shall be governed by the laws of the jurisdiction in which the institution is located. This form, if accepted by the institution, constitutes the entire waiver agreement between the Applicant and the institution with respect to the immunizations specified herein and supersedes all prior understandings, communications, or representations concerning the same.

CERTIFICATION

By signing below I certify under penalty of perjury that the statements in this form are true and correct to the best of my knowledge and belief. I understand that making a false statement may subject me to penalties under applicable law.

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