Statement of Exemption to Immunization Law

Commonwealth of Pennsylvania


 

Name: Date of Birth: Age:

Address:

Phone:

Check Present Grade:

PreK K 1 2 3 4 5 6 7 8 9 10 11 12 Sp.Ed.

Parent/Guardian:

Parent/Guardian:


Medical Exemption(a) The physical condition of the above named child is such that immunizations would endanger life or health.

Other Comment:

Physician Signature: Date:


Religious Exemption(b) (Includes a strong moral or ethical conviction similar to a religious belief.)

Parent or guardian of the above name child adheres to a religious belief whose teachings are opposed to such immunizations OR holds a strong moral or ethical conviction similar to a religious belief that is opposed to such immunizations.

Other Comments/Explanation:

Signature Parent/Guardian: Date:

Signature Parent/Guardian: Date:


PA 28§ 23.84. Exemption for immunization.

(a) Medical exemption. Children need not be immunized if a physician or designee provides a written statement that immunization may be detrimental to the health of the child. When the physician determines that immunization is no longer detrimental to the health of the child, the child shall be immunized according to this subchapter.

(b) Religious exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.