"Religious Exemption Statement Form" - Connecticut

Religious Exemption Statement Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on July 1, 2015;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Religious Exemption Statement Form" - Connecticut

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State of Connecticut
Department of Public Health
Religious Exemption Statement
__________________________________________
(Printed full, legal name of student)
I, the undersigned, do hereby swear or affirm, as the case may be as follows:
1. I am making this Religious Exemption Statement pursuant to Conn. Gen. Stat. § 10-204a so that
the student may enroll in school for the first time or enter seventh grade at
___________________________ school.
2. I am the lawful
parent
guardian of the student.
3. Immunizing said student would be contrary to
student’s
parent’s
guardian’s religious
beliefs.
4. I understand that by claiming this exemption the student shall be exempt from the immunizations
required by Conn. Gen. Stat. §§ 10-204a and 19a-7f.
5. I understand that during a vaccine-preventable disease outbreak at the above-identified school,
all susceptible children, including the student will be excluded from school if a public health
official determines that the school is a significant site for disease exposure, transmission and
spread into the community. In such case, such children, including the student shall be excluded
from school until: (1) the public health official determines that the outbreak danger has ended;
(2) the child becomes ill with the disease and completely recovers from it; (3) the child is
vaccinated according to public health protocol; or (4) the child has proof of immunity to the
disease.
______________________________
________________________
_______________
Name(s) of Parent(s)
Signature of Parent(s)/Guardian(s)
Date
______________________________
________________________
_______________
Name(s) of Parent(s)
Signature of Parent(s)/Guardian(s)
Date
________________________________________ __________________________________________
Address (Street & House or Apt. no.)
Telephone(s) no.
________________________________________
City, State and Zip Code
TO CLAIM A RELIGIOUS EXEMPTION, AN EXEMPTION FORM MUST BE SUBMITTED
TO THE PUBLIC OR NON-PUBLIC SCHOOL BEFORE ENROLLING IN THE SCHOOL FOR
TH
THE FIRST TIME AND BEFORE ENTERING SEVENTH (7
) GRADE.
State of Connecticut
Department of Public Health
Religious Exemption Statement
__________________________________________
(Printed full, legal name of student)
I, the undersigned, do hereby swear or affirm, as the case may be as follows:
1. I am making this Religious Exemption Statement pursuant to Conn. Gen. Stat. § 10-204a so that
the student may enroll in school for the first time or enter seventh grade at
___________________________ school.
2. I am the lawful
parent
guardian of the student.
3. Immunizing said student would be contrary to
student’s
parent’s
guardian’s religious
beliefs.
4. I understand that by claiming this exemption the student shall be exempt from the immunizations
required by Conn. Gen. Stat. §§ 10-204a and 19a-7f.
5. I understand that during a vaccine-preventable disease outbreak at the above-identified school,
all susceptible children, including the student will be excluded from school if a public health
official determines that the school is a significant site for disease exposure, transmission and
spread into the community. In such case, such children, including the student shall be excluded
from school until: (1) the public health official determines that the outbreak danger has ended;
(2) the child becomes ill with the disease and completely recovers from it; (3) the child is
vaccinated according to public health protocol; or (4) the child has proof of immunity to the
disease.
______________________________
________________________
_______________
Name(s) of Parent(s)
Signature of Parent(s)/Guardian(s)
Date
______________________________
________________________
_______________
Name(s) of Parent(s)
Signature of Parent(s)/Guardian(s)
Date
________________________________________ __________________________________________
Address (Street & House or Apt. no.)
Telephone(s) no.
________________________________________
City, State and Zip Code
TO CLAIM A RELIGIOUS EXEMPTION, AN EXEMPTION FORM MUST BE SUBMITTED
TO THE PUBLIC OR NON-PUBLIC SCHOOL BEFORE ENROLLING IN THE SCHOOL FOR
TH
THE FIRST TIME AND BEFORE ENTERING SEVENTH (7
) GRADE.
ACKNOWLEDGEMENT
STATE OF CONNECTICUT
:
:
ss:
COUNTY OF _______________________
:
On this the_____ day of _____________, _____, before me, ____________________________the
undersigned officer, personally appeared ___________________ known to me (or satisfactorily proven)
to be the person whose name he or she subscribed to the within instrument and acknowledged that he or
she executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand.
____________________________________
Judge
Family Support Magistrate
Clerk/Deputy Clerk (include seal)
Town Clerk
Notary Public My Commission expires (______________)
Justice of the Peace
Commissioner of the Superior Court (bar no.__________)
School Nurse (license no.__________________________)
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