HEALTH SERVICES

IMMUNIZATION EXEMPTION FORM #18A

STUDENT NAME: __________________________________ DOB _______________

1. MEDICAL CONTRAINDICATIONS:

The physical condition of the above named pupil is such that immunization at this time would constitute a serious threat to his/her health.

This is a: _____ Permanent Condition  _____ Temporary Condition

Check the appropriate box above, and indicate vaccine(s) which cannot be given and the reasons why:

________________________________________________________________________

________________________________________________________________________

Signed: ________________________________________________

                (Physician of Public Health Officer)

Date: __________________________________________________

2. RELIGIOUS CONTRAINDICATIONS:

This pupil is an adherent of a religion whose teachings are opposed to immunization.

Signed: _________________________________________________

(Parent/Guardian)

Date: ___________________________________________________