Student’s full name Birth Date Age Sex
If student is under 18, name of parent, guardian, or other person responsible for student’s care and custody:
Street address City Zip
Telephone: (home)__________________________________(work)___________________________________
I, the undersigned, swear or affirm that immunization against diphtheria, pertussis (whooping cough), tetanus,
polio, rubella, mumps, measles, H. influenzae type B, hepatitis B, and varicella is contrary to my religious tenets
and practices.
I understand that:
(1) I am subject to the penalty for false swearing if I falsely claim a religious exemption for the above-
named student [i.e. a fine of up to $500, up to 6 months in jail, or both (Sec. 45-7-202, MCA)];
(2) In the event of an outbreak of one of the diseases listed above, the above-exempted student may be
excluded from school by the local health officer or the Montana Department of Public Health and Human
Services until the student is no longer at risk for contracting or transmitting that disease; and
A new affidavit of exemption for the above student must be signed, sworn
to, and notarized yearly and kept together with the State of Montana Certificate of
Immunization (HES-101) in the school’s records.
Signature of parent, guardian or other person
responsible for the above student’s care and
custody; Or of the student, if 18 or older.
Subscribe and sworn to before me on this ________ day of ___________________, __________.
SEAL _____________________________________________
Notary Public for the State of Montana
Residing in ___________________________________
My commission expires__________________________
HES-113 10/99
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