Immunizations - Health Services - District Resources 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section 1. Enter the child's name, birth date, and the parent/guardian's name. Ensure all required fields marked with an asterisk (*) are completed.
3. Provide the telephone number and home address of the parent/guardian, including city, state, and zip code.
4. In the immunization contraindications section, select any vaccines that are medically contraindicated for your child. Be sure to include a reason for exemption.
5. Proceed to Section 2. Indicate the duration of the exemption and print/type the physician's name along with their office address and contact information.
6. Finally, ensure that the physician signs and dates the form before submission.

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