Name, __________________________ __ 3irthdl1e, _______________________ _

AddrelS, _____________________ _ !'arent or Guardianl ________________ _

ielephone' _____ . _____________ _

Please Circle Present Grade : K r---------------------

2 3 4 5 6 7 8 9 10 11 12 Sp. Ed. . - ., . MEDICAL E)( EMPTION

The physical condition of the above named child is such that immunizati,)n would endanger lif, or health.

S~Nd ----------------~IPH~YS~I~CI~A~N~l--------------Dlte ________ _

RELIGIOUS e:KEMPTION (In.c.lud •• a a_tronQ mOfal or ethical c:ornliction aimilar to a ,.Iigiot.!a be!~f.)

Parent or guardian of the above named child Idheres to a religious belief whon teachings Ife opposed to such immunizatioN.

Stlte your reason for requesting a religious .. emption ____________________________ _

Signed ________________ ~=:::_::;_,:::==_:=~-------------IPARENT OR GUAROIANl

Date ________ _

. " .. ;,:.;..,.; .. . . .:.... '" :~ -.. >: .. - .,

Name Birthdate

Address Parent or Guardian

Telephone

Please Circle Present Grade: K , 2 3 4 5 t 7 8 9 10 11 12 Sp. Ed. . - . ~rfi;; ;;y - ~~4 :i .'.1~ ~ [.1 ~~:! ... rJ.T.l,lIm'J"'-1h1~

' . . r ' .. : ......

MEDICAL EXEMPTION

The physical condition of the above named child is such that immunization 1V0uid endanger life or health,

Signed Date ~ P"'!Y SIC IAN ~

RELIGIOUS EXEMPTION \Includes a strong moral or athical conviction similar to I religious belief , I

Parent or guardian of the above named child adheres to a religious belief whose teachings are opposed to such immunizations.

State your reason for requesting a religious exemption

Signed Date IPARENT OR GUARDIAN'