Texas Department of State Health Services




Affidavit Request for Exemption from Immunizations for Reasons of Conscience

COVID-19 Update
1. The COVID-19 vaccine is NOT included on the vaccine exemption request affidavit as it is not a required vaccine at this time for people enrolled in child-care/Pre-K facilities, K-12 schools, colleges, or universities.

2. Texas DSHS staff continue to process conscientious exemption requests. Exemption requests are processed in the order they are received and it may take up to 3 weeks for requested affidavits to be mailed.

* Required fields

First name, last name, and birth date are required for each individual; the middle name is optional.
If exemptions are requested for only one individual, the information must be entered on the first line.
Valid birth dates are required; future birth dates are not allowed.


I wish to obtain an Exemption from Immunizations for Reasons of Conscience Affidavit Form. Please provide me with exemption affidavit forms for the individuals listed below (maximum 5 forms per individual).

Name of Parent, Legal Guardian, or Self
*    
*    
* (This should be your permanent U.S. mailing address.)
 

*  
*   *  
*
   

Please type the information below EXACTLY as you would like it to appear on the affidavit.

First Name
Middle Name
Last Name
Birth Date (mm/dd/yyyy)
Number of Forms
     
* 1
 
  2
 
  3
 
  4
 
  5
 
  6
 
  7
 
  8
 



   
Copyright 2012 Texas Department of State Health Services