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Refusal to Vaccinate Form Template

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Image 1

Prepared for:

​[Parent.FirstName][Parent.LastName]​

Prepared by:

​[Witness/Health Care Worker.FirstName][Witness/Health Care Worker.LastName]​

Child Details

Child's Name:

​[Child.FirstName][Child.LastName]​

Gender:

(child's gender)

Date of Birth:

(child's date of birth)

Age:

(child's age)

School Level:

(child's school level)

School Name:

(child's school name)

Parent/Guardian Details

Parent/Guardian Name:[Parent.FirstName][Parent.LastName]​

Address:[Parent.StreetAddress], [Parent.City], [Parent.State][Parent.PostalCode]​

Phone Number:[Parent.Phone]​

Email:[Parent.Email]​

Vaccinations

Influenza

Prevents a contagious respiratory illness caused by influenza viruses that can affect the nose, throat, and lungs and can cause mild to severe illness.

Decline:

Yes

No

Name of the medical professional who recommended:

MMR (Measles, Mumps, Rubella)

Prevents three viral diseases: measles, mumps, and rubella.

Decline:

Yes

No

Name of the medical professional who recommended:

Tetanus

Prevents tetanus, an infection caused by Clostridium tetani bacteria.

Decline:

Yes

​No

Name of the medical professional who recommended:

Polio

Prevents poliovirus, an infectious disease spread from person to person that can cause paralysis.

Decline:

Yes

No

Name of the medical professional who recommended:

Varicella (Chickenpox)

Prevents the infectious disease known as chickenpox which causes rashes all over the body.

Decline:

Yes

No

Name of the medical professional who recommended:

Diphtheria

Prevents an acute, highly contagious bacterial disease that can lead to severe respiratory or cardiovascular problems.

Decline:

Yes

No

Name of the medical professional who recommended:

Pertussis

Prevents whooping cough caused by Bordetella pertussis bacteria.

Decline:

Yes

No

Name of the medical professional who recommended:

Hepatitis B

Prevents liver infection by the Hepatitis B virus.

Decline:

Yes

No

Name of the medical professional who recommended:

Meningococcal

Prevents what is often a severe and deadly infection caused by Neisseria meningitidis bacteria that affects the brain and spinal cord.

Decline:

Yes

No

Name of the medical professional who recommended:

I have decided to decline the vaccine(s) recommended for my child, as indicated above, by stating "Yes" in the column titled "Decline."

Acknowledgments

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.

​

Signature
MM / DD / YYYY

​[Parent.FirstName][Parent.LastName]​

​

Signature
MM / DD / YYYY

​[Witness/Health Care Worker.FirstName][Witness/Health Care Worker.LastName]​

Refusal to Vaccinate Form Template

Used 4,886 times

This Refusal to Vaccinate Form Template is editable, allowing you to add information about you, your child, and the immunizations you choose to forgo. If appropriate, you can also mention the name of a doctor you've consulted.

Use this template — free
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FAQ

  • The easiest way to write a refusal to vaccinate form is to use a template like this one. All you need to do is input your child’s information, your information (if you’re the parent or guardian), which vaccines are being refused, and have the document signed by a witness or the child’s health care provider.

  • A refusal to vaccinate form is used by a parent or guardian to formally document which vaccines are being refused for their child. These forms are often used in school settings and may be required or voluntarily supplied. 

  • The reason to use a refusal to vaccinate form is if a parent or guardian wishes to document their refusal of certain vaccines for their child formally. There are numerous reasons a parent or guardian might refuse certain vaccines for their child, including religious, philosophical, or health reasons. If someone wanted their child to receive any vaccines available, they would not want to use a refusal to vaccinate form.

  • The essential details to include on a refusal to vaccinate form are the child’s identifiable information, the parent/guardian’s information, the specific vaccines being refused, and the signatures. It’s also important to state the name of the medical professional advising the guardian and, if possible, their signature confirming that they’ve talked with the parent about the vaccines.

  • You can get your child’s immunization records from your state’s immunization information system (IIS). Contact the IIS in your state to request an official copy. You can also contact your child’s doctor or clinic since they should have records on file if they have vaccinated your child. It’s also possible that your child’s school may have their vaccination records on file. Schools often maintain records for a year or two after a student graduates or transfers. 

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