Immunization Waiver 2017

VACCINATION EXEMPTION PURSUANT TO MICHIGAN
STATUTE MCLA § 333.9215

MCLA § 333.9215 is entitled "EXEMPTIONS":

(1) A child is exempt from the requirements of this part as to a specific immunization for any period of time as to which a physician certifies that a specific immunization is or may be detrimental to the child's health and is not appropriate;

(2) A child is exempt from this part if a parent, guardian in loco parentis of a child presents a written statement to the administrator of the child's school or operator of the group program to the effect that the requirements of this part cannot be met because of RELIGIOUS CONVICTIONS OR OTHER OBJECTIONS TO IMMUNIZATIONS.

The term OR OTHER OBJECTION TO IMMUNIZATION means that you as an individual or parent have the right to choose whether or not to vaccinate your child. The statute does not require you to disclose what other objection to immunization is. As with any medical decision, the decision to vaccinate or not is a right of the individual or parent. The State of Michigan, your doctor and public health employees cannot force you or your child to be vaccinated. Your child cannot be excluded from a school or public program because you have exercised your right not to vaccinate.

VACCINE EXEMPTION FORM

Parent Name*

I, as the parent, guardian or person in loco parentis of the child...

Child Name*

...after considering the risks and benefits of the vaccine(s) do hereby decide not to vaccinate my child with the following vaccines:*

You chose other, please explain

Pursuant to my right to refuse vaccination on the statutory grounds of "other objection to immunization.” Pursuant to the statute I am providing a copy of the statement to the child's school administrator or operator of the group program pursuant to MCLA § 333.9215(2).

Date*

Signature of Parent / Guardian or Person in loco parentis*

Digital Signature Acknowledgement*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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