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Fillable Printable Immunization Waiver Sample Form

Fillable Printable Immunization Waiver Sample Form

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
Parent/Guardian Signature Date
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