* 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.
Birth Date (mm/dd/yyyy)
Number of Forms