Get Print Affidavit For Exemption From Immunizations In California Form

Exemption From Immunizations AFFIDAVIT TO BE SIGNED BY PARENT OR GUADIAN I request exemption of my child from the immunization requirements for school entry because these immunizations are contrary to my personal beliefs. I understand that in a case of an outbreak of any of the diseases listed in subdivision a of Section 120335 that my child may be temporarily excluded from school for his or her protection. Print Name Date Signature California Health Safety Code IMMUNIZATION NOT REQUIRED WHEN CONTARY TO PERSONAL BELIEFS Immunization of a person shall not be required for admission to a school or other institution listed in Section 120335 if the parent or guardian or adult who has assumed responsibility for his or her care and custody in case of a minor or the person seeking admission if an emancipated minor files with the governing authority a letter or affidavit stating that immunization is contrary to his or her beliefs. Exemption From Immunizations AFFIDAVIT TO BE SIGNED BY PARENT OR GUADIAN I request exemption of my child from the immunization requirements for school entry because these immunizations are contrary to my personal beliefs. I understand that in a case of an outbreak of any of the diseases listed in subdivision a of Section 120335 that my child may be temporarily excluded from school for his or her protection* Print Name Date Signature California Health Safety Code IMMUNIZATION NOT REQUIRED WHEN CONTARY TO PERSONAL BELIEFS Immunization of a person shall not be required for admission to a school or other institution listed in Section 120335 if the parent or guardian or adult who has assumed responsibility for his or her care and custody in case of a minor or the person seeking admission if an emancipated minor files with the governing authority a letter or affidavit stating that immunization is contrary to his or her beliefs. However whenever there is good cause to believe that the person has been exposed to one of the communicable diseases listed in subdivision a of Section 120335 that person may be temporarily excluded from the school or institution until the local heath officer is satisfied that the person is no longer at risk of developing the disease. Added by Stat. 1995 Ch* 415 Sec 7 MEDICAL CONDITIONAL MAKING IMMUNIZATION UNSAFE If the parent or guardian files with the governing authority a written statement by a licensed physician to the effect the physical condition of the child is such or medical circumstances relating to the child are such that immunization is not considered safe indicating the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization that person shall be exempt from the requirements of Chapter 1 commencing with Sections 120325 but excluding Section 120380 and Sections 120400 120405 120410 and 10415 to the extent indicated by the physician s statement. I understand that in a case of an outbreak of any of the diseases listed in subdivision a of Section 120335 that my child may be temporarily excluded from school for his or her protection* Print Name Date Signature California Health Safety Code IMMUNIZATION NOT REQUIRED WHEN CONTARY TO PERSONAL BELIEFS Immunization of a person shall not be required for admission to a school or other institution listed in Section 120335 if the parent or guardian or adult who has assumed responsibility for his or her care and custody in case of a minor or the person seeking admission if an emancipated minor files with the governing authority a letter or affidavit stating that immunization is contrary to his or her beliefs. However whenever there is good cause to believe that the person has been exposed to one of the communicable diseases listed in subdivision a of Section 120335 that person may be temporarily excluded from the school or institution until the local heath officer is satisfied that the person is no longer at risk of developing the disease.