Refusal to Vaccinate Form Template

Child Details

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.