"Immunization Exemption Form - Broadreach" - Maine

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IMMUNIZATION EXEMPTION FORM
As a parent/guardian of ____________________________________________, I am requesting a waiver
Child’s name
for the following required immunizations:
All required Immunizations
DTAP (Diphtheria, Tetanus and Pertussis)
IPV/ OPV (Polio)
MMR
Varicella (Chicken Pox)
HIB (Haemophilus influenzae type B)
Hepatitis A
Hepatitis B
PCV 7 (Pneumococcal Conjugate)
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 the program and program activities. The length of time my child will be kept out of
the program may vary from a week to over a month depending on the disease and length of the outbreak.
I am requesting this waiver because of:
My sincere religious belief
Philosophical reasons
Medical Reasons (I have attached the required MD verification.)
My explanation is as follows: __________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________
___________
Signature
Date
__________________________________________________
Relationship to student, if not a parent
www.broadreachmaine.org
5 Stephenson Lane, Belfast, Maine 04915 telephone 207-338-2200
IMMUNIZATION EXEMPTION FORM
As a parent/guardian of ____________________________________________, I am requesting a waiver
Child’s name
for the following required immunizations:
All required Immunizations
DTAP (Diphtheria, Tetanus and Pertussis)
IPV/ OPV (Polio)
MMR
Varicella (Chicken Pox)
HIB (Haemophilus influenzae type B)
Hepatitis A
Hepatitis B
PCV 7 (Pneumococcal Conjugate)
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 the program and program activities. The length of time my child will be kept out of
the program may vary from a week to over a month depending on the disease and length of the outbreak.
I am requesting this waiver because of:
My sincere religious belief
Philosophical reasons
Medical Reasons (I have attached the required MD verification.)
My explanation is as follows: __________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________
___________
Signature
Date
__________________________________________________
Relationship to student, if not a parent
www.broadreachmaine.org
5 Stephenson Lane, Belfast, Maine 04915 telephone 207-338-2200