PARENT OR GUARDIAN - FILL OUT THESE SECTIONS
Immunizations already received:
I have provided the school with a record of all immunizations the student has received that are required for admission (California Health and Safety Code §120365)
Immunizations for which exemption is requested:
An unimmunized student and the student’s contacts at school and home are at greater risk of becoming ill with a vaccine-preventable disease. I understand that an unimmunized student may be excluded from attending school during an outbreak of, or after exposure to, any of the diseases for the protection of the other students. I hereby request exemption of the student named above from the required vaccine checked below because such vaccine is contrary to my beliefs.