CO Request

* Required fields

I wish to obtain an Exemption from Immunizations for Reasons of Conscience Affidavit Forms.

Name of Parent, Legal Guardian, or Self
* First Name first name required.
* Last Name last name required.

* Address to which Affidavit Forms should be mailed (This should be your permanent U.S. mailing address.)
mail-address required.

Apartment/Unit/Suite Number

* City city required.
* State * Zipcode zip required.

* Phone (valid phone numbers in these formats are accepted: (234) 567-8989, (234) 567.8989, 2345678989, 234-567-8989, 234.567.8989)
phone # required. Please enter a valid phone number using an acceptable format.

Please provide me with * forms. Form Count required.
(maximum 5 forms per individual).

Affidavit Request for Exemption from Immunizations for Reasons of Conscience