Requesting an Exemption for Reason of Conscience

To claim an exclusion for reasons of conscience, including a religious belief, the child's parent, legal guardian, or a student 18 years of age or older must present to the school or child-care facility a completed, signed and notarized affidavit on a form provided by the department stating that the child's parent, legal guardian, or the student declines vaccinations for reasons of conscience, including because of the person's religious beliefs.

Submitting an Exemption for Reasons of Conscience

The form must be submitted to the school or child-care facility within 90 days from the date it is notarized.  The affidavit will be valid for a two-year period from the date of notarization.  A child or student who has not received the required immunizations for reasons of conscience, including religious beliefs, may be excluded from school in times of emergency or epidemic declared by the commissioner of the department.

How to Obtain an Affidavit

This affidavit is to request exclusion for reasons of conscience, including religious belief, from required school immunizations.  A parent or legal guardian may request this affidavit on behalf of their child or student using the forms and methods outlined below.  The request must include the following information:

• Full name of child or student
• Child or student's date of birth (month/ day/ year)
• Complete mailing address, including telephone number
• Number of requested affidavit forms (not to exceed 5).

Request a Vaccine Exemption

To place an order, e-mail us at lookandsee09@gmail.com or call 682-622-1665.

Please pay the $30 processing fee using the link below and allow 7-10 days for delivery.