JLCB-E (FORM) - YEARLY IMMUNIZATION EXEMPTION FORM

Any student who is not fully immunized must have this form on file prior to the first day of each school year.

As a parent/guardian of ____________________________________, date of birth, __________, I am requesting a waiver for the following immunizations for the __________________ school year.

All required immunizations: ___

DTAP ____

IPV/OPV ____ 

MMR ____

Varicella ____

Tdap* ____

MCV4** ____

• designates required immunization for incoming 7th graders
• **designates required immunization for incoming 7th and 12th graders

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 arrangements for my child to receive and complete school assignments and to make up missed examinations and other work within a reasonable time upon their return to school.

I have read and acknowledge the State of Maine Immunization Requirements for School Children - Chapter 126.

Parent/Guardian Initials: ___________

I am requesting a waiver for:

___ Sincere Religious Belief

___ Philosophical Reason

My explanation is as follows: _____________________________________________________

Parent/Guardian signature: _____________________________________ Date:_____________

I am requesting a waiver for:

___ Medical Exemption

Physician statement as to reason for medical exemption to immunization: ___________________________

Parent/Guardian signature: _____________________________________ Date:_____________

Physician signature: __________________________________________ Date:_____________