Vaccine Letters -
Below are some sample Vaccine Exemption Letters that you use for required school vaccination for yourself or your children (also in pdf & doc below).
The short form below is from Windward Community College, which is a part of the University of Hawaii (UH) system.
It was the form at their Health Office, and may be able to be used in conjunction with another long-form vaccine exemption letter.
All forms and letters may be altered for use with your particular state (check state statutes for vaccination exemption requirements).
REQUEST FOR EXEMPTION FROM IMMUNIZATION ON RELIGIOUS GROUNDS:
I certify that immunization conflicts with my bona fide religious tenets and practices.
I understand that I am susceptible to vaccine preventable diseases. If at any time there is, in the opinion of the Department of Health, danger of an outbreak or epidemic from any communicable disease for which immunization is required, this exemption from immunization shall not be recognized. I understand that I will be excluded from school until the threat of an epidemic is over or I receive the proper immunization. (Hawaii Revised Statutes '302A-1157).
Name (Please Print) ___________________________________
Birthdate __ /__ /____
School/University ________________________________________
Signature __________________________________
Date __ /__ /____
Epi 7B April 2002
Below are some sample Vaccine Exemption Letters that you use for required school vaccination for yourself or your children (also in pdf & doc below).
The short form below is from Windward Community College, which is a part of the University of Hawaii (UH) system.
It was the form at their Health Office, and may be able to be used in conjunction with another long-form vaccine exemption letter.
All forms and letters may be altered for use with your particular state (check state statutes for vaccination exemption requirements).
REQUEST FOR EXEMPTION FROM IMMUNIZATION ON RELIGIOUS GROUNDS:
I certify that immunization conflicts with my bona fide religious tenets and practices.
I understand that I am susceptible to vaccine preventable diseases. If at any time there is, in the opinion of the Department of Health, danger of an outbreak or epidemic from any communicable disease for which immunization is required, this exemption from immunization shall not be recognized. I understand that I will be excluded from school until the threat of an epidemic is over or I receive the proper immunization. (Hawaii Revised Statutes '302A-1157).
Name (Please Print) ___________________________________
Birthdate __ /__ /____
School/University ________________________________________
Signature __________________________________
Date __ /__ /____
Epi 7B April 2002
| exemptionvaclib-hawaii.pdf |
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