STATE OF OHIO

LEGAL IMMUNIZATION EXEMPTION

Per OHIO STATUTE 3313.671 (Exemptions) 

Religious, Good Cause, and Medical Exemption Form Amended Substitute Senate Bill No. 282. Ohio Revised

Code. Sections 3313.671. Pat (3) and (4)

Section 3313.671, part (3): A pupil who presents a written statement of his parent or guardian in which the parent or guardian objects to the immunization for good cause, including religious convictions, is not required to be immunized.

Section 3313.671 part (4): A child whose physician certifies in writing that such immunization against any disease is medically contraindicated is not required to be immunized against that disease. This section does not limit or impair the right of a board of education of a city, exempted village, or local school district to make and enforce rules to secure immunization against poliomyelitis, rubeola, rubella, diphtheria, pertussis, and tetanus of the pupils under it jurisdiction.

I understand that the immunization Law permits me to sign a waiver on my child taking the immunization.

I hereby object and request the school to waiver the immunization of my child against the following: (mark the boxes of the vaccines to which you object)                                

Child’s Name:        ________________________________________________________________

My Objection is:

• Religious: List name of denomination __________________________________________

OR

• Good Cause: Please explain______________________________________________________

OR

• Medical Reason: You must have a signed statement from your physician stating the condition and attach it to this form.

I further understand that during the course of an outbreak of any of the aforementioned vaccine preventable diseases, that the student named here is subject to exclusion from school for the duration of the outbreak.

This action is necessary not only to protect this student, but the remainder of the students and faculty of the school.

Parent/Guardian Signature: __________________________________________________________

Address: _____________________________________________________ Date: ______________