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Here are the vaccine exemption forms and/or information for every state in the U.S.

post #1 of 17
Thread Starter 
Here are the vaccine exemption forms and/or information for all 50 states.

If you're nosy, check out your state's exemption rates. http://www.msnbc.msn.com/id/26337586

"A written objection from the parent or guardian of a student based on religious tenets and practices shall be submitted in person by the parent or guardian to the County Health Department for issuance of a Certificate of Religious Exemption from the required immunizations or testing."
http://www.adph.org/Immunization/ass...hoolImmLaw.pdf (1st page)

Alaska Immunization Requirements Religious Exemption Form
(go to page 52)

Alaska Immunization Requirements Medical Exemption Form
(go to page 51)

Arizona child care centers
Request For Exemption to Immunization

Arizona schools
Request for Exemption to Immunization

http://www.healthyarkansas.com/rules...ments_2004.pdf (pages 4 and 5)

California School Immunization Record

Colorado childcare and schools
Colorado Department of Public Health and Environment -- Certificate of Immunization

Colorado colleges and universities
Certificate of Immunization for College Students

Religious Exemption Certification Form

http://delcode.delaware.gov/title14/...tml#P227_51758 (contains exact wording for exemption affidavit)

District of Columbia
"No certification of immunization shall be required for the admission to a school of a student:
(1) For whom the responsible person objects in good faith and in writing, to the chief official of the school, that immunization would violate his or her religious beliefs; or (2) For whom the school has written certification by a private physician, his or her representative, or the public health authorities that immunization is medically inadvisable." (D.C. Code 38-506)

Immunization Guidelines Florida Schools, Childcare Facilities, and Family Daycare Homes
text of florida law regarding immunizations
Form to opt out of "SHOTS" (State Health Online Tracking System)

Georgia childcare and schools
Immunization Guidelines for Child Care Facility Operators and School Personnel
http://health.state.ga.us/pdfs/preve...uctions.03.pdf (page 2)
"If there is a religious exemption, the parent/guardian must give the facility/school a signed and dated notarized statement or affidavit stating that immunizations are against their religious beliefs. This affidavit should be filed instead of the Certificate of Immunization. The affidavit does not expire."

Georgia colleges and universities
University System of Georgia Certificate of Immunization

http://hawaii.gov/health/family-chil...alth-faqs.html "Religious exemption forms may be completed at the school that your child will attend."

The Hawaii religious exemption form states, "I certify that immunization conflicts with my bona fide religious tenets and practices. I understand that my child is susceptible to vaccine preventable diseases. If at anytime there is, in the opinion of the Department of Health, danger of an outbreak or epidemic from any communicable disease for which immunization is required, this exemption shall not be recognized. I understand that my child will be excluded from school until the threat of an epidemic is over or he or she receives the proper immunization. (Hawaii Revised Statutes Section 302A-1157)"

Idaho child care
State of Idaho Certificate of Exemption Child Care Immunization Requirement

Idaho schools
State of Idaho Certificate of Exemption

Note on Idaho exemption forms: You may not feel comfortable initialing those statements that you understand you are putting your child at risk. Idaho law does not require that you use those forms.
Idaho law for child care: http://www3.state.id.us/cgi-bin/newi...id=390110018.K
Idaho law for schools: http://www3.state.id.us/cgi-bin/newi...id=390480002.K

law regarding exemptions http://www.ilga.gov/commission/jcar/...50000300R.html

"A religious objection must be in writing and state that the objection to immunization is based on religious grounds; signed by the child’s parent; and delivered to the school. There is no requirement of proof. The written objection must be resubmitted to the school each year." https://chirp.in.gov/chirp_files/doc...008-2009V2.pdf

Iowa Department of Public Health Certificate of Immunization Exemption

Certificate of Immunizations

Commonwealth of Kentucky Childhood Immunization Law Certificate of Religious Exemption (EPID-230C) http://www.owen.k12.ky.us/attendance...ERTIFICATE.doc

Louisiana Handbook for School Administrators
cut and paste the address above into your web browser.
(from page 29) "No student seeking to enter any school shall be required to comply with the provisions of this Section if the student or his parent or guardian submits either a written statement from a physician stating that the procedure is contraindicated for medical reasons, or a written dissent from the student or his parent or guardian is presented."


Maryland Department of Health and Mental Hygiene Immunization Certificate http://edcp.org/pdf/896_form.pdf
Meningococcal waiver information for college http://edcp.org/html/meningupdate.html

The parent or guardian should state "in writing that vaccination or immunization conflicts with his sincere religious beliefs."

Text of law regarding exemptions to vaccines: http://www.legislature.mi.gov/(S(yd3...e=mcl-333-9215
Official exemption form: http://www.momvaccines.org/miform.pdf
Alternate exemption form if you don't want to admit to putting your child at risk: http://www.momvaccines.org/momform.pdf
Opt-out form for the Michigan Care Improvement Registry (MCIR), which is a vaccine registry http://www.mcir.org/forms/OptOut%20Form%20Jan07.pdf

Submit a notarized statement that all or some immunizations are against your "conscientiously held beliefs." (Do not need to be religious beliefs).
Text of statute:

Only allows medical exemptions to vaccines. They are very difficult to get. A physician (M.D. or D.O.) can request a medical exemption, but a government health official decides whether or not to grant it. Vaccines are not required for homeschooling.
Text of statute:
If you want to work toward changing the law, here is the link to the Mississippi Vaccine Information Center.


For a religious exemption, ask for the HES-113 form from the Department of Public Health and Human Services. It must be notarized every year.

Refusal of Immunization of Student for Religious Reasons

Refusal of Immunization for Medical Reasons

"NRS 392.437 Immunization of pupils: Exemption if prohibited by religious belief. A public school shall not refuse to enroll a child as a pupil because the child has not been immunized pursuant to NRS 392.435 if the parents or guardian of the child has submitted to the board of trustees of the school district or the governing body of a charter school in which the child has been accepted for enrollment a written statement indicating that their religious belief prohibits immunization of such child or ward."

New Hampshire

New Jersey

New Mexico
Certificate of Exemption From School/Daycare Immunization Requirements

New York
Request for Religious Exemption to Immunization Form
(Many New York residents have had their requests for exemption denied. You need to research and be very careful about the wording before you submit the request).

North Carolina
vaccination exemption information

North Dakota
Certificate of Immunization

text of law: http://codes.ohio.gov/orc/3313.671 "A pupil who presents a written statement of the pupil’s parent or guardian in which the parent or guardian declines to have the pupil immunized for reasons of conscience, including religious convictions, is not required to be immunized."
Brochure about Ohio's immunization registry, and how to opt out: http://www.odh.ohio.gov/ASSETS/A3A45...A/impactsi.pdf

http://www.oklahomahealthfreedom.org...ertificate.pdf (day care and school exemption form)
http://www.oklahomahealthfreedom.org/exemptions.html (college exemption information)

Oregon Certificate of Immunization Status
This is the brochure you are supposed to read before signing the religious exemption:

law regarding exemptions for child care http://www.pacode.com/secure/data/02...27/s27.77.html
law regarding exemptions for school http://www.pacode.com/secure/data/02...23/s23.84.html

Rhode Island
Daycare, preschools, and schools http://www.health.state.ri.us/immuni...ol-schools.pdf
Colleges and universities http://www.health.state.ri.us/immuni...University.pdf (page 5)S

South Carolina
A South Carolina Certificate of Religious Exemption may be obtained from the Department of Health and Environmental Control. (DHEC Form 1126) Here is a directory of offices. http://www.scdhec.net/health/countymap.htm. You must go in person to get the form. It must be notarized.

South Dakota

Religious Exemption from Vaccination
text of statute


Utah School and Early Childhood Program Immunization Guidebook 2008/2009.

Request to Withdraw from the Utah Statewide Immunization Information System

School Immunization Exemption Form

Certificate of Religious Exemption

Washington state
Certificate of Exemption (COE) From School, Child Care, and Preschool Immunization Requirements

West Virginia
Only allows medical exemptions to vaccines
If you want to work toward changing the law, here is a link to "West Virginians for Vaccination Exemption"

http://www.legis.state.wi.us/statutes/Stat0252.pdf (page 2) "The immunization requirement is waived if the student, if an adult, or the student’s parent, guardian or legal custodian submits a written statement to the school, day care center or nursery school objecting to the immunization for reasons of health, religion or personal conviction."

Rules and Regulations for School Immunizations: http://wdh.state.wy.us/familyhealth/...n/schools.html (Click on "Minimum Immunization Requirements) (2nd page)
Info on immunization registry and opting out: http://wdh.state.wy.us/familyhealth/...tion/WyIR.html (Click on "WyIR Opt Out Form")
post #2 of 17
New York

In NYS, use the NYSED form above whenever you can. Keep your "explanation of beliefs" short, simple, and to the point. Be certain to note your objection to ALL vaccines.

Don't use a form letter from the internet or another source - schools may be looking for these, and can then question your sincerity. ALWAYS use your own words in your explanation of beliefs.
post #3 of 17
Immunization laws/statutes & exemption info for all states in the US is listed here (scroll down the page for clickable map).
post #4 of 17
Thank you for the links! I enrolled DC's in school today and boy did I make a few heads turn when I could not produce shot records. Thanks again
post #5 of 17
Bookmarking, thanks!
post #6 of 17
Thank You
post #7 of 17
Could we make this a sticky?
post #8 of 17

Thanks. This would make a great sticky!
post #9 of 17
I wish we had a subforum specifically for exemptions. It would make specific info so much easier to find.
post #10 of 17
Here's the form for Tennessee.

post #11 of 17
Here are some exemption forms for every state, also


post #12 of 17
We'll leave it here for a bit since it's a compilation in progress & then move it once it seems complete.
post #13 of 17

Vaccines Declined form for pediatrician's office

How about a copy of this form, a modified version of the form many peds try to get parents to sign...

Modified AAP Refusal of Vaccination Form

Consent Declined for Vaccines

Child’s Name ________________________________________

Child’s ID#____________________

Parent’s/Guardian’s Name(s)___________________________________________

My child’s health care provider, ___________________, has advised me that my child (named above)
should receive the following vaccines:

Vaccines: Recommended and/or Declined

Hepatitis BY/NY/N__/__/__
DT or TdY/NY/N__/__/__
Haemophilus influenza type B (Hib)Y/NY/N__/__/__
Pneumococcal conjugate vaccineY/NY/N__/__/__
Polio vaccine (IPV)Y/NY/N__/__/__
Measles, mumps, rubella MMR-IIY/NY/N__/__/__
Varicella (chickenpox)Y/NY/N__/__/__
Influenza (flu)Y/NY/N__/__/__
Hepatitis AY/NY/N__/__/__
Total _____________/__/__

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining the vaccine(s) and the disease(s) for which it is intended. I have had the opportunity to discuss this with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine(s). I understand the following:

● The intended purpose of the recommended vaccine(s).
● The risks and benefits of the recommended vaccine(s).
● If my child does not receive the vaccine(s), the consequences may include
- Contracting the illness the vaccine should prevent. (the outcomes of these illnesses may include one or more of the following: pneumonia, illness requiring hospitalization, death, brain damage, meningitis, seizures, and deafness. Other severe and permanent effects from these vaccine -preventable diseases are possible as well)
- Transmitting the disease to others.
- The need for my child to stay out of child care or school during disease outbreaks.

●If my child does receive the vaccine(s), the consequences may include:
-Contracting the illness the vaccine should have prevented
-Transmitting the disease to others
-Suffering from any of the adverse events listed in the package insert and possibly adverse events not
yet listed and/or associated with the vaccine. (the outcomes of these adverse events may include one or more of the following: illness requiring hospitalization, death, brain damage, meningitis, seizures, and deafness. Other severe and permanent effects from these vaccines are possible as well)
-Chronic illness and/or death

● My health care provider, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention have all strongly recommended that the vaccine(s) be given based on the information they have been given by the drug companies producing the vaccines.

I have declined consent for the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled “Declined.”

I know that I may re-address this issue with my health care provider at any time, and that I may change my mind as personal beliefs are subject to evolve and change over time.

I acknowledge that I have read this document in its entirety and fully understand it.

Parent/Guardian Signature ______________________________________



post #14 of 17
No disrespect to you Suschi ... but since people often confuse the Refusal to Vaccinate form (NOT a legal document) with an exemption form (a legal document), perhaps a separate thread for that?

They're very different forms with very different purposes and I just don't like to see them used interchangeably, or one confused for the other.

Or maybe your post could be added to an existing thread concerning RtV forms - I know there are several such threads in the forum.
post #15 of 17
Exemptions go hand in hand with either a document a ped wants to have on file, or a copy of the actual exemption filed, which is why I posted it here.

In most cases, a copy of the exemption form should be sufficient for the ped in lieu of the "refusal form"...but some parents don't mind signing such a form or a version of the form.

It may be a good idea to have that as an FYI at the beginning of the sticky, that if a parent doesn't want to sign a refusal form, they can give their ped a copy of the exemption instead...

or not.

Just throwing it out there, really doesn't matter to me either way if it's included or not. Take a vote.
post #16 of 17
post #17 of 17
moving to archive - please PM a vax moderator with any additions or updates.
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