THIS IS TO CERTIFY THAT:
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Name of Student
Should be exempted from the following immunizations:
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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:
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Type your name here as a signature (If you are under 18, your Parent/Guardian must type their name as a signature):
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Email:
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example@example.com
Student ID Number:
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Date:
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-
Month
-
Day
Year
Submit
If you are human, leave this field blank.
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Should be Empty: