PERSONAL BELIEFS EXEMPTION FOR COVID-19 VACCINATION PERSONAL BELIEFS EXEMPTION STUDENT NAME (LAST, FIRST, MIDDLE)(Required) GENDER(Required) BIRTHDAY MONTH/ DAY/ YEAR(Required) PARENT/GUARDIAN – NAME(Required) PARENT/GUARDIAN - TELEPHONE NUMBER(Required) Email(Required) ADDRESS(Required) PARENT OR GUARDIAN - FILL OUT THESE SECTIONSReceipt of Information:(Required)1. The benefits and risks of the COVID-19 vaccination 2. The health risks to the student above and to the community of the communicable diseases for which vaccine is required in California. I have received information provided by an authorized health care practitioner regarding the above information. Personal Beliefs(Required) Personal Beliefs:My personal beliefs prohibit me from allowing my child to be vaccinated for COVID-19. Parent Signature (Please Print Name)(Required) AFFIDAVITImmunizations 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.Check box(es) to request exemption(Required) K-12th Grade | COVID-19 Vaccination Parent Signature (Please Print Name)(Required)
