VACCINE - Louisburg USD 416 2026

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The document is a Kansas Certificate of Immunizations - Form B, which provides a template for medical exemptions from vaccinations for students. It requires details about the student, the parent/guardian, and the specific vaccines for which an exemption is requested. A licensed medical professional must certify that the child's health condition justifies the exemption, and this form must be attached to the student's immunization records annually.

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Click ‘Get Form’ to open the VACCINE - Louisburg USD 416 in the editor.
Begin by entering the student's name and birthdate in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the address details, including street address, city, state, and zip code. This helps in maintaining proper records.
Provide parent or guardian information along with a telephone number for any necessary follow-up.
Indicate the medical exemption reason by checking the appropriate box next to each vaccine listed. Be thorough to ensure all relevant vaccines are noted.
The certifying physician must sign and date the form. Include their printed name, address, telephone number, medical license number, and state of licensure.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (97 Votes)
2019	4.4 Satisfied (136 Votes)
2018	4.4 Satisfied (129 Votes)
2015	4 Satisfied (60 Votes)
2011	4.4 Satisfied (244 Votes)

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