THIS IS TO CERTIFY THAT:
*
Name of Student
Should be exempted from the following immunizations:
*
MMR (Measles, Mumps and Rubella)
Meningitis ACYW
Other
Please identify your religious belief, practice or observance and explain why it precludes you from receiving the vaccination(s) checked above:
*
Type your name here as a signature (If you are under 18, your Parent/Guardian must type their name as a signature):
*
Email:
*
example@example.com
Student ID Number:
*
Date:
*
-
Month
-
Day
Year
Submit
If you are human, leave this field blank.
Should be Empty: