SAMPLE
XYZ Charter
719
555/555-1234
IMMUNIZATION AFFIDAVIT
I, ___________________________________, the parent of __________________________, date of birth_____________________, am requesting a religious exemption from state immunizations required for attendance in school on the grounds that immunizations conflict with the tenets and practices of our recognized religious organizations, __________________, of which the applicant is an adherent of member. I realize that this exemption does not apply in times of emergency or outbreak declared by the commissioner of health or local health authority.
___________________ ___________________________________________
Date Parent signature
(acknowledgement)
STATE OF
BEFORE ME, the undersigned Notary Public, on this _____ day of ___________, 20__, personally appeared_________________________, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she has executed the same for the purposes and considerations therein expressed.
____________________________________
Notary
Public-State of
Print
Name: _______________________
II. 40