CERTIFICATE OF RELIGIOUS EXEMPTION

Name__________________________________ Birthdate_______________________

Address_______________________________________________________________

The administration of immunizing agents conflicts with the above named student’s religious beliefs. I understand that in the occurrence of an outbreak of vaccine-preventable disease in my child’s school, the State Health Director may exclude my child from school, for his/her own protection, until the danger has passed.

________________________________________ ____________________________

Signature of Parent/Guardian/Student Date

I hereby affirm that this affidavit was signed in my presence on this _______________ day of __________________, 19____.

Notary Public Seal: