In the “Decline” section, select the answer you want and delete the other; e.g., if you wish to decline a specific vaccine, delete “No” and leave “Yes.”
1. I confirm that I have been informed that my child might be at risk of being affected by one or more of the aforementioned communicable diseases if the appropriate vaccine is not taken.
2. I understand that without these vaccines, the child is susceptible to communicable diseases that could be prevented by utilizing the vaccine.
3. I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining how the vaccine(s) work and the disease(s) they have been created to prevent.
4. I acknowledge that medical professionals and health workers have advised me about the advantages and disadvantages of not accepting these vaccines.
5. I understand that the department's health and the government shall not be liable if the child is infected by a communicable disease.
6. I acknowledge that my child may be held out of school, gatherings, or any other extracurricular programs if there's an outbreak that they are not vaccinated for.
7. I accept that this document may be shared with any appropriate facilities or institutions if necessary.
8. I acknowledge that I have read this document in its entirety and fully understand it.