* Required fields
First name, last name, and birth date are required for each individual; the middle name is optional.
If exemptions are requested for only one individual, the information must be entered on the first line.
Valid birth dates are required; future birth dates are not allowed.
I wish to obtain an Exemption from Immunizations for Reasons of Conscience Affidavit Form. Please provide me with exemption affidavit forms for the individuals listed below
(maximum 5 forms per individual).
Name of Parent, Legal Guardian, or Self
*First Name
*Last Name
*Address to which Affidavit Forms should be mailed (This should be your permanent mailing address.)
Apartment/Unit/Suite Number
*City
*State
*Zipcode
*Phone (valid phone numbers in these formats are accepted: (234) 567-8989, (234) 567.8989, 2345678989, 234-567-8989, 234.567.8989)
Please type the information below EXACTLY as you would like it to appear on the affidavit.
First Name
Middle Name
Last Name
Birth Date (mm/dd/yyyy)
Number of Forms