Fillable Printable Immunization Waiver Form - Michigan

Immunization Waiver Form - Michigan

CAPITOL VIEW BUILDING • 201 TOWNSEND STREET • LANSING, MICHIGAN 48913

www.michigan.gov • 517-373-3740 DCH-1272 (01 /1 1)

IMMUNIZATION WAIVER FORM

INSTRUCTIONS TO PARENTS OR GUARDIAN S:

Vaccine-preventable diseases are still wit h us. Immunizations are one of the most cost-effective measures to protect chil d r en from

harmf ul dis eases and even death. A high proportion of c hildren must be i mmunized to prevent outbreaks of disease in school settings

and other places where children wor k and play closel y together.

Sections 9208 and 9211 of the Michigan Public Health Code require that a parent, guardian, or person in loco parentis applying to

have a c hild r e gistered for the first time in a Michigan school and/or in 6

grade, or in a program of group residence, care, or camping

in this state shall present to officials at the time of re gistration or no t la te r than the first day of school or program enrollment, a

certificate of immuniza tion verifying that the child has been vacc inated against diphther ia , tetan us, p e rtussis, measle s, mumps, rubella,

polio, hepatitis B, and varicella (chickenpox). Pneumococcal conjugate and Haemophilus influenzae type b vaccines are also require

for preschool-aged children. Meningoco ccal vaccine is required for children 11 years of age or older who are in the 6

grade or newly

enrolle d in the district.

A parent or guardian wishing to exempt his or her child from a particular vaccination must pro vide a written statement i ndicating the

religious or philosophical objections to the vacci nation(s). A child who has been exempted from a vaccinatio n is considered

susceptible to the disease or diseases for which the vaccinatio n offers protection. The child may be subject to exclusion from the

schoo l or p r o gram, i f the local and/or state public health authorit y advises excl usion as a disease control measure.

B y si gni n g thi s wai ve r , you ac knowle d ge that yo u are placing your child and others at risk of serious i llness should he or she contract

a disease that could have been p revented throu gh proper vaccination.

ALL INFORMATION MUST BE FILLE D IN BE L OW.

I object to having my child, , born , immu nized with the

vaccines I have checked below: (First & Last Nam e) (Birth Date)

⁪

DTaP, DT, Td, Tdap (Diphtheria, Tetanus, Pertussis)

⁪

Haemophilus influenzae type b

⁪

Polio

⁪

Pneumococcal Conjugate

⁪

Hepatitis B

⁪

Varicella (chickenpox)

⁪

MMR (Measles, Mumps, Rubella)

⁪

Meningococcal

Reason:

Parent(s)/Guardian(s) Name:

Address: Telephone:

Chi l d's Addre ss Telephone:

If different from parent/guardian

_________________________________________________________________ ___________________________

Parent or Guardi an's Si gnature Date Signed

_______________________________________________________________

Preschool Program or Licensed Day Care Center OR School Name (Required)

File in the child's permane nt rec ord and send a copy to you r local health department.

DCH-0716 AU THORITY: P.A. 368 of 1 978, Part 92 Rev. 3/2011