Exemption Request Form
(Medical/Religious Immunization Exemption)
Personal Information
Full Name
Date of Birth
Email
Phone Number
Address
Exemption Type
Select Exemption Type
Medical
Religious
Immunization(s) Requested for Exemption
List vaccine(s) or immunization(s)
Reason for Exemption
Please provide your detailed reason:
Supporting Documentation
Attach documentation (if applicable):
Signature
Signature
Date