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 2020-2021 school year.

**All required immunizations: **𝥷

**DTAP 𝥷 IPV/OPV 𝥷 MMR 𝥷 Varicella 𝥷 *Tdap 𝥷 **MCV4 **𝥷

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:_____________


Revision #3
Created 26 October 2021 20:26:49 by Troy Patterson
Updated 14 February 2023 21:21:36 by Jennifer Lakari