"Immunization Exemption Form - Girl Scouts of Northern California" - California

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Download "Immunization Exemption Form - Girl Scouts of Northern California" - California

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Immunization Exemption Form
What is the purpose of this form?
What is the purpose of this form?
What is the purpose of this form?
What is the purpose of this form?
Because our camps have a potential for communicable diseases, we recommend that program participants are appropriately
immunized for, at minimum, the following diseases: tetanus, mumps, measles, rubella, polio, smallpox, pertussis (whooping
cough), and diphtheria. This being said, we recognize that some individuals may not be fully immunized for reasons that are
biophysical (e.g., the individual is allergic to a serum component) or of personal choice (e.g., faith belief). This form is intended
to capture information about individuals who are not fully immunized.
Who should complete this form?
Who should complete this form?
Who should complete this form?
Who should complete this form?
• A custodial parent/legal guardian of an underage participant/camper who is not fully immunized.
• An adult participant, including a staff member, who is not fully immunized.
I request that ________________________________________, enrolled in session ______________ be exempted from the
Name of Individual
immunizations required for attendance at Girl Scouts of Northern California camps. The reason for this request is as follows:
_________________________________________________________________________________________________
To the best of my knowledge and belief, the person named above is and has been in normal good health and is free from all
communicable or contagious disease. Should this participant show symptoms that reasonably indicate the presence of a
communicable or contagious disease, I agree that a physical examination may be performed. I also agree that if any such
disease is found, we – the named individual and his/her family – will comply with the quarantine or isolation procedures
required of Girl Scouts of Northern California as directed by the state’s Department of Health. I understand the refund policy
for this camp.
It is further understood that, should a communicable disease emergency arise, I will be notified. However, in the event that I
cannot be contacted, the camp’s administrator(s) and healthcare staff may take the temporary measures they deem
necessary to protect the health status of this participant.
I release and forever discharge Girl Scouts of Northern California and each and every one of its officers, directors, employees,
agents, insurers, affiliates, attorneys, or any other person or persons associated with any or all of them or any variation in the
name of any or all of them who might be liable (the Released Parties) from all causes of action, suits, claims, demands, or any
other damages or costs associated with actions taken by the Released Parties relative to the health, sickness and treatment
of
_____________________________________________.
Name of Individual
I further understand and acknowledge that I make this release in full accord and satisfaction of and in compromise of any
current or future disputed or alleged claims or causes of action relative to the health, sickness and treatment of
_____________________________________________ against the Released Parties.
Name of Individual
I represent and acknowledge that I have read and understand this agreement and release and warrant that all statements
made herein are true to the best of my knowledge. I further warrant and acknowledge that I am of legal age, legally competent
to execute this agreement and release, and accept full responsibility therefore.
Signature
Signature of Parent/Guardian:
Signature
Signature
of Parent/Guardian:
of Parent/Guardian:
of Parent/Guardian:
Date:
__________________________
_______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
Street Address
City
State
Phone Number
Immunization Exemption Form
What is the purpose of this form?
What is the purpose of this form?
What is the purpose of this form?
What is the purpose of this form?
Because our camps have a potential for communicable diseases, we recommend that program participants are appropriately
immunized for, at minimum, the following diseases: tetanus, mumps, measles, rubella, polio, smallpox, pertussis (whooping
cough), and diphtheria. This being said, we recognize that some individuals may not be fully immunized for reasons that are
biophysical (e.g., the individual is allergic to a serum component) or of personal choice (e.g., faith belief). This form is intended
to capture information about individuals who are not fully immunized.
Who should complete this form?
Who should complete this form?
Who should complete this form?
Who should complete this form?
• A custodial parent/legal guardian of an underage participant/camper who is not fully immunized.
• An adult participant, including a staff member, who is not fully immunized.
I request that ________________________________________, enrolled in session ______________ be exempted from the
Name of Individual
immunizations required for attendance at Girl Scouts of Northern California camps. The reason for this request is as follows:
_________________________________________________________________________________________________
To the best of my knowledge and belief, the person named above is and has been in normal good health and is free from all
communicable or contagious disease. Should this participant show symptoms that reasonably indicate the presence of a
communicable or contagious disease, I agree that a physical examination may be performed. I also agree that if any such
disease is found, we – the named individual and his/her family – will comply with the quarantine or isolation procedures
required of Girl Scouts of Northern California as directed by the state’s Department of Health. I understand the refund policy
for this camp.
It is further understood that, should a communicable disease emergency arise, I will be notified. However, in the event that I
cannot be contacted, the camp’s administrator(s) and healthcare staff may take the temporary measures they deem
necessary to protect the health status of this participant.
I release and forever discharge Girl Scouts of Northern California and each and every one of its officers, directors, employees,
agents, insurers, affiliates, attorneys, or any other person or persons associated with any or all of them or any variation in the
name of any or all of them who might be liable (the Released Parties) from all causes of action, suits, claims, demands, or any
other damages or costs associated with actions taken by the Released Parties relative to the health, sickness and treatment
of
_____________________________________________.
Name of Individual
I further understand and acknowledge that I make this release in full accord and satisfaction of and in compromise of any
current or future disputed or alleged claims or causes of action relative to the health, sickness and treatment of
_____________________________________________ against the Released Parties.
Name of Individual
I represent and acknowledge that I have read and understand this agreement and release and warrant that all statements
made herein are true to the best of my knowledge. I further warrant and acknowledge that I am of legal age, legally competent
to execute this agreement and release, and accept full responsibility therefore.
Signature
Signature of Parent/Guardian:
Signature
Signature
of Parent/Guardian:
of Parent/Guardian:
of Parent/Guardian:
Date:
__________________________
_______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
Street Address
City
State
Phone Number