Get Doh 348 106 June 2011 Pdf Filler

Certificate of Exemption For School Child Care and Preschool Immunization Requirements1 DOH 348-106 June 2011 DIRECTIONS All exemptions must have a licensed health care provider sign date Box 1 Provider Statement. Exception Box 1 is not required for religious exemptions when Box 2 Demonstration of Religious Membership is completed* All exemptions must also have a parent/guardian sign date Box 3 Parent/Guardian Statement. Child s Last Name First Name Middle Initial Parent/Guardian Name please print Birthdate mm/dd/yyyy Sex Temporary Medical Exemption Permanent Medical Exemption Personal/Philosophical Exemption see Box 1 Religious Exemption see Box 1 Religious Membership Exemption see Box 2 Until Vaccine s Date or Permanent Print Name of Licensed Health Care Provider MD DO ND PA ARNP X Signature of Licensed Health Care Provider I do not want my child to get the following vaccine s Diphtheria Measles Pneumococcal Tetanus Hepatitis B Hib Mumps Pertussis whooping cough Polio Rubella Varicella chickenpox Date Other indicate Box 1 Box 2 Provider Statement I am a qualified provider MD DO ND PA ARNP licensed under Title 18 RCW* I confirm that the parent or guardian signing in Box 3 and risks of immunization to their child as a condition for exempting their child for medical religious personal or philosophical reasons. member of a church or religious body whose beliefs or teachings do not allow for medical treatment from a health care practitioner. By supplying the information requested below no further proof or signed provider statement in Box 1 is required for this religious exemption* Name of Church or Religious Body Signature of Parent or Guardian Box 3 outbreak of a vaccine-preventable disease my child has not been fully immunized against as indicated above for medical personal/philosophical or religious reasons my child may be at risk for disease and can be excluded from school child care or preschool until the outbreak is over. If you have a disability and need this document in a different format please call 1 800 525 0127 TDD/TTY 1 800 833 6388. RCW 28A. 210. 080 090 states that before or on the first day of every child s attendance at any public and private school or licensed child care center in Washington State the parent or guardian must present proof of either 1 full immunization 2 the initiation of and compliance with a schedule of immunization as required by rules of the State Board of Health or 3 a A letter may substitute for a signed Provider Statement on this certificate. To be accepted the letter must reference the child s name on this certificate confirm that the child s parent or guardian got information on the risks and benefits of immunization to their child and be signed by a licensed health care provider. Exception Box 1 is not required for religious exemptions when Box 2 Demonstration of Religious Membership is completed* All exemptions must also have a parent/guardian sign date Box 3 Parent/Guardian Statement. Child s Last Name First Name Middle Initial Parent/Guardian Name please print Birthdate mm/dd/yyyy Sex Temporary Medical Exemption Permanent Medical Exemption Personal/Philosophical Exemption see Box 1 Religious Exemption see Box 1 Religious Membership Exemption see Box 2 Until Vaccine s Date or Permanent Print Name of Licensed Health Care Provider MD DO ND PA ARNP X Signature of Licensed Health Care Provider I do not want my child to get the following vaccine s Diphtheria Measles Pneumococcal Tetanus Hepatitis B Hib Mumps Pertussis whooping cough Polio Rubella Varicella chickenpox Date Other indicate Box 1 Box 2 Provider Statement I am a qualified provider MD DO ND PA ARNP licensed under Title 18 RCW* I confirm that the parent or guardian signing in Box 3 and risks of immunization to their child as a condition for exempting their child for medical religious personal or philosophical reasons.