Request for Religious Exemption to Immunization

A written and signed statement from the parent, parents, or guardian of such child, stating that the parent, parents or guardian objects to their child’s immunization due to sincere and genuine religious beliefs which prohibit the immunization of their child in which case the principal or person in charge may require supporting documents.

In the area provided below, please write your statement. The statement must address all of the following elements:
• Explain in your own words why you are requesting this religious exemption.
• Describe the religious principles that guide your objection to immunization.
• Indicate whether you are opposed to all immunizations, and if not, the religious basis that prohibits particular immunizations.

You may attach to this form additional written pages or other supporting materials if you so choose. Examples of such materials are listed on page 3.
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Please sign in the space provided below and have the document notarized by a notary public where indicated.

I hereby affirm the truthfulness of the forgoing statement and have received and reviewed the informational immunization materials provided to me by my child’s school.

__________________________________________ _____________________________
Signature of Parent/Guardian Date

Sworn to before me this____________________________ day of ___________________

[Notary Public Seal]

You will be notified in writing of the outcome of this request. Please note that if your request for an exemption is denied, you may appeal the denial to the Commissioner of Education within thirty (30) days of the decision, pursuant to Education Law, Section 310.

Request for Religious Exemption to Immunization Form (continued ) Page 3 of 4

SECTION BELOW FOR SCHOOL DISTRICT USE ONLY

To the Building Principal:

If, after review of the parental statement, questions remain about the existence of a sincerely held religious belief, Department of Health regulation [10 NYCRR, Section 66-1.3(d)] permits the principal to request supporting documents. Some examples include:

• A letter from an authorized representative of the church, temple, religious institution, etc. attended by the parent/guardian, literature from the church, temple, religious institution, etc. explaining doctrine/beliefs that prohibit immunization (Note: Parents/guardians need not necessarily be a member of an organized religion or religious institution to obtain a religious exemption);
• Other writings or sources upon which the parent/guardian relied in formulating religious beliefs that prohibit immunization;
• A copy of any parental/guardian statements to healthcare providers or school district officials in a district of prior residence explaining the religious basis for refusing immunization;
• Any documents or other information the parent/guardian may be willing to provide that reflect a sincerely held religious objection to immunization (for example: disclosure of whether parent/guardian or other children have been immunized, parent/guardian’s current position on allowing himself or herself or his or her children to receive or refuse other kinds of medical treatment.)

Reviewer Name
(Building Principal):____________________________________________

Indicate Result of Request Review:

o APPROVED - Date of Approval_______________
o DENIED - Date of Denial _______________

State Specifically Reason(s) for Denial: ____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

You may attach additional sheets if necessary.

Reviewer Signature (Building Principal) ___________________________________

● Parent/guardian must be notified in writing of the approval or denial of the request. If the request is denied, the notification letter must include the specific reason(s) for denial.
● If a religious exemption request is denied, the parent/guardian may appeal the denial to the Commissioner of Education within thirty (30) days of the decision, pursuant to Education Law, Section 310.