HomeMy WebLinkAbout3004F1 Idaho School Immunization ExemptionIDAHO SCHOOL IMMUNIZATION REQUIREMENTS EXEMPTION
In the event of a disease outbreak, a child exempted from Idaho school immunization requirements may be excluded from school
for the duration of the outbreak. Please check the box(es) below, and date each line regarding all vaccine-preventable diseases for
which an exemption is claimed.
MEDICAL EXEMPTION (This exemption requires the signature of a licensed physician.)
As the child’s physician, I certify that the physical condition of this child is such that the immunization(s) checked above would endanger the
health of the child.
This medical exemption is permanent.
This medical exemption is temporary. Duration of temporary exemption: _______/_______/________
I hereby request that this child be exempted from the Immunization Requirements for Idaho School Children (IDAPA 16.02.15) due to a
medical condition for which immunizations are contraindicated.
__________________________________________ ________________________________________ _____________________
Name of Physician (PRINT)Signature of Physician Medical License # Date
As the child’s parent/guardian, I understand that in the event of a disease outbreak my child may be excluded from school for the duration of
the outbreak. By signing this form, I am not waiving any of my child’s rights to an education under Article 9, Section 1 of the Idaho Constitution
if my child is excluded from school during a disease outbreak.
__________________________________________ ________________________________________ _____________________
Name of Parent/Guardian (PRINT)Signature of Parent/Guardian Date
__________________________________________ _________________________
Full Name of Exempted Child (PRINT) Child’s Date of Birth (Month, Day, Year)
RELIGIOUS/OTHER EXEMPTION
As the child’s parent/guardian, I am exempting for religious or other reasons. I understand that in the event of a disease outbreak my child
may be excluded from school for the duration of the outbreak. By signing this form, I am not waiving any of my child’s rights to an education
under Article 9, Section 1 of the Idaho Constitution if my child is excluded from school during a disease outbreak.
__________________________________________ ________________________________________ _____________________
Name of Parent/Guardian (PRINT)Signature of Parent/Guardian Date
__________________________________________ _________________________
Full Name of Exempted Child (PRINT) Child’s Date of Birth (Month, Day, Year)
OPTIONAL: Parents/guardians may include a signed written statement regarding religious/other exemptions on the back/Page 2 of this document.
Diphtheria (DTaP, Tdap, Td) _______
Date
Tetanus (DTaP, Tdap, Td) _______
Date
Pertussis (Whooping Cough) (DTaP, Tdap) _______
Date
Measles (MMR) _______
Date
Mumps (MMR) _______
Date
Rubella (German Measles) (MMR) _______
Date
Polio _______
Date
Hepatitis B _______
Date
Hepatitis A _______
Date
Meningococcal _______
Date
Varicella (Chickenpox)
Varicella Disease History: My child has had
chickenpox but was not diagnosed by a licensed
healthcare professional.
_______
Date
_______
Date
All required immunizations _______
Date
Child’s Name: _________________________________
Provided for school use by the Idaho Department of Health and Welfare Idaho Division of Public Health Page 1 Revised: 1/2018
I decline to provide details regarding my child’s exemption status. NOTE: Your child will be considered exempt from all
required school immunizations.
3004F1
Provided for school use by the Idaho Department of Health and Welfare Idaho Division of Public Health Page 2 Revised 1/2018
OPTIONAL STATEMENT:
As the child’s parent/guardian, I exempt my child from school immunizations for the following reason(s):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________ ________________________________________ _____________________
Name of Parent/Guardian (PRINT)Signature of Parent/Guardian Date