Name, ____________________________
3irthdl1e, ________________________
AddrelS,______________________
!'arent or Guardianl _________________
Please Circle Present Grade :
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ielephone' _____.______________
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Sp. Ed.
MEDICAL E)( EMPTION The physical condition of the above named child is such that immunizati,)n would endanger lif, or health. Dlte _ _ _ _ _ _ _ __
S~Nd ----------------~IPH~YS~I~CI~A~N~l-------------RELIGIOUS e:K EMPTION
(In.c.lud•• a a_tronQ mOfal or ethical c:ornliction aimilar to a ,.Iigiot.!a be!~f.)
Parent or guardian of the above named child Idheres to a religious belief whon teachings Ife opposed to such immunizatioN. Stlte your reason for requesting a religious ..emption _____________________________
Date _ _ _ _ _ _ _ __
Signed ________________~=:::_::;_,:::==_:=~------------IPARENT OR GUAROIANl
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Name
Birthdate
Address
Parent or Guardian
Please Circle Present Grade:
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MEDICAL EXEMPTION The physical condition of the above named child is such that immunization 1V0uid endanger life or health, Signed
Date ~ P"'! Y SIC I AN ~
RELIGIOUS EXEMPTION \Includes a strong moral or athical conviction similar to I religious belief , I
Parent or guardian of the above named child adheres to a religious belief whose teachings are opposed to such immunizations. State your reason for requesting a religious exemption
Signed
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Telephone
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Date IPARENT OR GUARDIAN'
Sp. Ed. ' . .r ' ..