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Certificate of Exemption For School Child Care and Preschool Immunization Requirements1 DOH 348-106 June 2011 DIRECTIONS All exemptions must have a licensed health care provider sign date Box 1 Provider Statement. Exception Box 1 is not required for religious exemptions when Box 2 Demonstration of Religious Membership is completed* All exemptions must also have a parent/guardian sign date Box 3 Parent/Guardian Statement. Child s Last Name First Name Middle Initial Parent/Guardian Name please print Birthdate mm/dd/yyyy Sex Temporary Medical Exemption Permanent Medical Exemption Personal/Philosophical Exemption see Box 1 Religious Exemption see Box 1 Religious Membership Exemption see Box 2 Until Vaccine s Date or Permanent Print Name of Licensed Health Care Provider MD DO ND PA ARNP X Signature of Licensed Health Care Provider I do not want my child to get the following vaccine s Diphtheria Measles Pneumococcal Tetanus Hepatitis B Hib Mumps Pertussis whooping cough Polio Rubella Varicel....

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How to use or fill out the Doh 348 106 June 2011 Pdf Filler online

Filling out the Doh 348 106 June 2011 Pdf Filler is an essential step for parents and guardians seeking an exemption from school, child care, and preschool immunization requirements. This guide will walk you through each section of the form to ensure accurate completion.

Follow the steps to effectively fill out your exemption certificate.

  1. Press the ‘Get Form’ button to access the Doh 348 106 June 2011 Pdf Filler. This action will allow you to open the form in your preferred editor.
  2. Begin by entering the child’s last name, first name, and middle initial in the designated fields.
  3. Next, fill in the parent or guardian's name as it should appear in print along with the child’s birthdate in the format mm/dd/yyyy.
  4. Indicate the child’s sex by selecting the appropriate option from the provided choices.
  5. Choose the applicable exemption(s) by checking the corresponding box for Temporary Medical Exemption, Permanent Medical Exemption, Personal/Philosophical Exemption, or Religious Exemption.
  6. If necessary, specify the vaccine(s) your child should not receive by checking the respective boxes. You can also fill in other information if applicable.
  7. Complete Box 1 by having a licensed health care provider sign and date it if any medical exemptions are selected. If claiming a religious exemption and using Box 2, ensure that section is completed.
  8. In Box 3, the parent or guardian must sign and date the statement confirming that all provided information is accurate.
  9. Once all relevant sections of the form are filled, review your information for accuracy. Users can then save changes, download a copy, print, or share the filled form as needed.

Complete your exemption certificate online to ensure your child's immunization requirements are properly managed.

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