Fillable Printable Immunization Waiver Sample Form

Immunization Waiver Sample Form

IMMUNIZATION WAIVER

I/We, the parent(s)/legal

guardian(s) of hereby acknowledge that

my/our child is not immunized according to the immunization schedule recommended by the

American Academy of Pediatrics.

Please mark the appropriate statement as it applies to this child:

My/Our child has not received ANY immunizations.

My/Our child has not received the following immunizations:

My/Our child has not been immunized according to the immunization schedule

recommended by the American Academy of Pediatrics for the following reason:

Medical Disability (Attach a letter from a certified Health Care Provider

detailing the specific medical disability which precludes the child from receiving

immunizations.)

Religious Doctrine, Tenant or Law (Attach a letter from your religious leader

detailing the mandated religious tenant, doctrine or law which precludes the child

from receiving immunizations.)

Personal Conviction or Creed (Attach a personal statement detailing the personal

conviction or creed which precludes the child from receiving immunizations.)

I/We further recognize that my/our child is at risk of contracting the disease(s) he/she is not

immunized against and that should he/she contract any of these diseases he/she will be

excluded from participating in the program until he/she is no longer contagious, as per the

programs Communicable Diseases Policy. I/We recognize that while many other children in

the child care program are immunized, this does not mean that the bacteria/viruses that cause

these diseases are not present in the center. In fact, it is likely that the bacteria/viruses are

present as a natural part of life and may present a risk of infection to my/our child.

Recognizing all of these factors, as well as others discussed with my/our child’s health care

provider, I/we have made the conscious choice not to immunize my/our child and will not hold

Shady Lane Child Development Center responsible, liable nor negligent in any way should

my/our child contract one or more of the diseases for which he/she not immunized.

Parent/Guardian Signature Date