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The certificate grants a religious exemption from required immunizations for school entry in Kentucky.
The form requires the child's full name and birthdate to be filled out.
It necessitates the name and address of the parent or guardian signing the document.
The certificate must be signed by a licensed healthcare professional, such as a physician, APRN, PA, pharmacist, LHD administrator, or nurse designee.
The completed certificate should be presented to the school or facility where the child intends to enroll.
Schools or facilities are required to retain this certificate and file it with the child's health record.
The form has a revision date noted as EPID-230C (Rev 08/2010), indicating its last update.