Name of Student

As a parent/guardian of __________________________________________ in grade ______, I am requesting a waiver for the following immunizations:

c DTAP c IPV c MMR c Varicella

I understand that in the case of an outbreak of the specific disease for which my child is not protected, my child will be kept out of school and school activities. The length of time my child will be kept out of school may vary from a week to over a month depending on the disease and length of the outbreak. I also understand that if my child is kept out of school, the school is not required to provide off-site classes or tutoring. The school may make reasonable accommodations to assist my child in keeping up with classwork.

I am requesting a waiver for:

c Sincere Religious Belief c Philosophical Reason

My explanation is as follows:

Signature Relationship to Student Date

___________________________________________________________________________