CERTIFICATE OF EXEMPTION
Please read instructions on the reverse of this certificate before completing.
All entries must be legible or form will be returned. Please print unless signature is required.
_______________________________________________ ____________________ ________________________________________________________
Name of Child (Last, First, MI) Birth Date Name of School / Child Care Facility / Head Start
_____________________________________ ______________ _________ ________________________ _____________________________
Parent/Guardian’s Name School Year Grade Facility Phone Number School District
_______________________ ___________________________________ __________________________________ ___________
Parent Phone Number County City Zip
TYPE OF EXEMPTION (Complete either section 1, 2 or 3 and sections 4 & 5)
1. MEDICAL CONTRAINDICATION:
I hereby certify that the immunization(s) specified below are medically contraindicated for the above named child.
________________________________________________________
_______________________________________________________
Immunization(s) State the condition that would endanger the life or health of the child.
____________________________________________ _______________________________________________________
Printed name of Physician Signature of Physician
_________________________________________________ _______________________________________________________
Address of Physician Phone number of Physician
2. RELIGIOUS OBJECTION:
I hereby certify that immunization is contrary to the teachings of the above named child’s religion.
___________________________________________________ ___________________________________________________
Printed name of Religious Leader or Parent/Guardian Signature of Religious Leader or Parent/Guardian
3. PERSONAL OBJECTION:
I hereby certify that immunization is contrary to my beliefs. As the parent or legal guardian of the above named child, I request an
exemption to the immunization requirements for School, Child Care Facility or Head Start attendance. I have written a brief summary
of my objections in the space provided below. I understand that lost records are not grounds for an exemption.
REQUIRED: Summary of Objections: (Limited to 600 characters.)
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
4. Please check which immunizations this exemption applies to:
DTaP/Td/Tdap
(Diphtheria, Tetanus & Pertussis)
Hepatitis A
Hepatitis B
Hib
(Haemophilus Influenzae type B)
MMR
(Measles, Mumps and Rubella)
Pneumococcal
Polio
Varicella (Chickenpox)
All
5. Acknowledgement
I understand that in the event of a disease outbreak in the School, Child Care Facility or Head Start, my child may have to be excluded
for his/her protection and for the protection of the other children in the School, Child Care Facility or Head Start.
_________________________________________________ ________________________________________________ ____________________
Printed name of Parent/Guardian Signature of Parent/Guardian Date
ATTENTION: PARENT/GUARDIAN – This form is to be submitted to the School, Child Care Facility or Head Start.
The School, Child Care Facility or Head Start should keep a copy of this form and mail the original to:
Oklahoma State Department of Health
Immunization Service - 0306
1000 N.E. 10
tth
Street
Oklahoma City, Oklahoma 73117-1299
ODH Form 216-A (Revised 08/12) For Questions Call: 405-271-4073
Oklahoma State Department of Health For forms, visit: http://imm.health.ok.gov
This section reserved for use by OSDH.
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