VACCINE EXEMPTION FORM - OHIO


Notice:
Many states are passing statutes to make school mandated vaccine exemptions more difficult to get. Also, many pediatricians and other health care professionals are giving parents a new form: Refusal to Vaccinate.
Go to the DO NOT SIGN page for more information.




January 22, 2012

EXEMPTION FORM TO OPT OUT OF SCHOOL MANDATED VACCINATIONS



STATE OF OHIO
LEGAL IMMUNIZATION EXEMPTION
Per Ohio Statute 3313.671

3313.671 Proof of required immunizations - exceptions.
http://codes.ohio.gov/orc/3313.671

Effective Date: 09-30-1998; 05-06-2005


(4) A pupil who presents a written statement of the pupil’s parent or guardian in which the parent or guardian declines to have the pupil immunized for reasons of conscience, including religious convictions, is not required to be immunized.

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(Name of Student)

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(Name of School)

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(Name of City)


As Legal Parents(s)/Guardians I/We:


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(Parent/guardian name)

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(Parent/guardian name)


do not give our consent for our child to receive vaccinations or immunizations in any form including injection, nasal mist, oral medication or any other method of delivery. Our beliefs prohibit such practices. This declaration is in accordance with the Ohio Statute 3313.671 - exemptions for reasons of conscience including religious convictions.

TO BE FILED WITH OUR CHILD'S SCHOOL HEALTH RECORD AS LEGAL PROOF OF OUR DECISION

Signature: ——————————————— Date: ———————

Signature: ——————————————— Date: ———————