*To be filed with student records
I am the parent of : (Child(ren) Name)
The State Sanitary Code (26:1A-9.1) provides for "exemption for pupils from mandatory immunization if the parent or guardian
of the pupil objects thereto in a written statement signed by the parent or guardian upon the ground that the proposed immunization
interferes with the free exercise of the pupil's religious rights."
I do therefore hereby certify that the proposed immunization interferes with the free exercise of the child's religious
rights. The administration of immunizing agents conflicts with the child's exercise of religious tenets or practices in that
we object to the administration of such agents by injection or orally based upon our religious beliefs.
The school accepts that while some students may have received immunizations, we respect the right for those records to
remain private with the family and therefore signing this exemption does NOT certify that NO immunizations have occurred but
rather that such records are the property of the parent.
[Signature of Parent ] _________________________________
Print Father's Name DATE
Print Mother's Name DATE