STATE OF OHIO

LEGAL IMMUNIZATION EXEMPTION

Per OHIO STATUTE 3313.671 (Exemptions)

Religious, Good Cause and Medical Exemption form

Ohio revised Code Section 3313.671 Part B 1-5

3313.671 Proof of required immunizations - exceptions.

(B) (1) A pupil who has had natural rubeola, and presents a signed statement from the pupil's parent,

guardian, or physician to that effect, is not required to be immunized against rubeola.

(B) (2) A pupil who has had natural mumps, and presents a signed statement from the pupil's parent,

(B) (5) A child whose physician certifies in writing that such immunization against any disease is

medically contraindicated is not required to be immunized against that disease.

I understand that the Law permits me to sign a waiver to my child receiving vaccinations.

I hereby object and request the school to waive the proof of vaccination of my child against some or all

of the following:

Child’s Name:______________________________________________________________

□ Religious: If desired, attach a page with religious statement or a letter from your religious leader.

I further understand that during the course of an outbreak of any of the aforementioned vaccine

preventable diseases, that the student named here is subject to exclusion from school for the

duration of the outbreak.

Parent/Guardian Signature:____________________________________________________

Address:_________________________________________________ Date:_____________

Revised 9/2017 Immunization Page 7