Certificate of Exemption From Immunizations

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Date *

YYYY

School Year *

School *

Becket Washington Elementary

Craneville Elementary

Kittredge Elementary

Nessacus Regional Middle

Wahconah Regional High

Student Name *

As a parent/caregiver of the student named above, a minor enrolled in Central Berkshire Regional School District, I request that they be exempt from the immunization requirements in accordance with the provisions of Chapter 76, Section 15, General Laws of Massachusetts, because such requirements conflict with our sincere religious beliefs.

I understand when a case of a vaccine-preventable disease emerges, susceptible individuals (including those with medical or religious exemptions) who are not immunized will need to be excluded for the appropriate time periods as outlined in Reportable Diseases, Surveillance and Isolation & Quarantine Requirements (105 CMR 300.000).

I also understand I will be asked annually to submit in writing my child’s immunization exemption status. I may also choose to have my child immunized against certain diseases but remain exempt from others according to my religious beliefs.

Parent/Caregiver Name *

By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *

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