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    MICHIGAN 2009 IMMUNIZATION WAIVER FORM SS Imm Waiver 2009

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    Donna
    This immunization waiver form allows parents to exempt their child from required vaccinations for medical or philosophical reasons. It must be signed by the parent and filed with the child's school or daycare. By signing, the parent acknowledges they are putting their child and others at risk of illness by not vaccinating. The parent must check which vaccines they are objecting to and provide a reason for the objection.

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    Download as PDF, TXT or read online from Scribd

    MICHIGAN 2009 IMMUNIZATION WAIVER FORM SS Imm Waiver 2009

    Uploaded by

    Donna
    936 views1 page
    This immunization waiver form allows parents to exempt their child from required vaccinations for medical or philosophical reasons. It must be signed by the parent and filed with the child's school or daycare. By signing, the parent acknowledges they are putting their child and others at risk of illness by not vaccinating. The parent must check which vaccines they are objecting to and provide a reason for the objection.

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    IMMUNIZATION WAIVER FORM

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    This immunization waiver form allows parents to exempt their child from required vaccinations for medical or philosophical reasons. It must be signed by the parent and filed with the child's school or daycare. By signing, the parent acknowledges they are putting their child and others at risk of illness by not vaccinating. The parent must check which vaccines they are objecting to and provide a reason for the objection.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    936 views1 page

    MICHIGAN 2009 IMMUNIZATION WAIVER FORM SS Imm Waiver 2009

    Uploaded by

    Donna
    This immunization waiver form allows parents to exempt their child from required vaccinations for medical or philosophical reasons. It must be signed by the parent and filed with the child's school or daycare. By signing, the parent acknowledges they are putting their child and others at risk of illness by not vaccinating. The parent must check which vaccines they are objecting to and provide a reason for the objection.

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    IMMUNIZATION WAIVER FORM

    INSTRUCTIONS TO PARENTS OR GUARDIANS:


    Vaccine-preventable diseases are still with us. In many cases, they cause disability or death. Immunizations are one of our most cost-
    effective measures to protect children from harmful diseases. A high proportion of children must be immunized to prevent outbreaks of
    disease in school settings and other places where children work and play closely together.

    Sections 9208 and 9211 of the Michigan Public Health Code require that a parent, guardian, or person in loco parentis applying to have a
    child registered for the first time in a Michigan school or in a program of group residence, care, or camping in this state shall present to
    officials at the time of registration or not later than the first day of school or program enrollment, a certificate of immunization verifying
    that the child has been vaccinated against diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis B, and varicella
    (chickenpox). Vaccination for Pneumococcal conjugate is also required for preschool-aged children. The Haemophilus influenza type b
    is not required for the 2009-20010 reporting season.

    A parent or guardian wishing to exempt his or her child from a particular vaccination must provide a written statement indicating the
    religious or philosophical objections to the vaccination(s). A child who has been exempted from a vaccination is considered susceptible
    to the disease or diseases for which the vaccination offers protection. The child may be subject to exclusion from the school or program,
    if the local and or state public health authority advises exclusion as a disease control measure.

    By signing this waiver, you acknowledge that you are placing your child and others at risk of serious illness should he or
    she contract a disease that could have been prevented through proper vaccination.

    ALL INFORMATION MUST BE FILLED IN BELOW.

    I object to having my child, , born , immunized against the


    diseases I have checked below: (First & Last Name) (Birth Date)

     Diphtheria  Measles  Hepatitis B


     Tetanus  Mumps  Haemophilus influenzae type b
     Pertussis  Rubella  Pneumococcal Conjugate
     Varicella (chickenpox)  Polio

    Reason:_____________________________________________________________________________________________________

    ___________________________________________________________________________________________________________

    Parent(s)/Guardian(s) Name:____________________________________________________________________________________

    Address: Telephone:_______________________________________

    Child's Address: Telephone:_______________________________________


    If different from parent/guardian

    _________________________________________________________________ _____________________
    Parent or Guardian's Signature Date Signed

    ___________________________________________________________
    Preschool Program or Licensed Day Care Center OR School Name (Required)

    File in the child's permanent record and send a copy to your local health department.
    DCH-0716 AUTHORITY: P.A. 368 of 1978, Part 92 Rev. 5/2009
    CAPITOL VIEW BUILDING  201 TOWNSEND STREET  LANSING, MICHIGAN 48913
    DCH-1272 (07/05) (W) www.michigan.gov  (517) 373-3740

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