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PARENT/GUARDIAN RELIGIOUS OBJECTION TO IMMUNIZATION REQUIRED BY INDIANA LAW (I.C. 20-34-3-2)

I have been informed by the school nurse and or the school principal of the immunization requirements stated in the Indiana Code 20-34-3-2.
I have also been informed of the availability of the required immunizations provided through the Allen County Public Health Department free of charge and the Super Shot Program free of charge, if I am unable to pay the Super Shot small fee.
I am also aware for the safety of my child that he/she will be dismissed from class in the event of an epidemic involving a vaccine-preventable disease.

Student Last Name*

Answer required for "Student Last Name"

Student First Name*

Answer required for "Student First Name"

Student Date of Birth*

Answer required for "Student Date of Birth"

Student Grade Level*

Answer required for "Student Grade Level"

Student Gender*

Answer required for "Student Gender"

Parent Last Name*

Answer required for "Parent Last Name"

Parent First Name*

Answer required for "Parent First Name"

Parent Address*

Street Address, City, State Zipcode

Answer required for "Parent Address"

Email Address*

Answer required for "Email Address"

Phone Number*

Number Required

Signature (Typing your full name will be regarded as your signature.)*

Signature Required

Please fix the highlighted areas below before submitting.