INSTRUCTIONS
2009-2010 School Year Only
Please read the entire application & Vaccine Information Statements
1) Complete the entire application only
2) Only one exemption per school year
3) Return pages 2, 3 and 4 of the application
4) Do not alter the application – altered application(s) will be returned
5) Do not abbreviate name of school
6) Check only one exemption (per application)
Helpful hints to complete the application
1) County not Country
2) Race/Ethnicity – Choose only one:
Alaska Native
American Indian
Asian Native Hawaiian/Pacific Islander
Black
Hispanic/Latino
White
Other
3) Include complete street address of daycare, school or college
4) Name of school district – Not district number
(Daycare/College will have no district)
5) Date enrolled – student’s first day of school of the 2009-2010 School
Year - not date registered
6) Daytime telephone number and (if applicable) e-mail address
Note: Cannot process application without the above information
See Page 1, Paragraph 2
If returned, a red check (√) will indicate the correction(s) needed
2
Arkansas
Exemption Application
2009 - 2010 School Year
General Information
Arkansas School Immunization Law (Act 999 of 2003) states that individuals shall complete
an annual application for all exemptions and include all of the following:
a notarized statement by the individual requesting the exemption and
an educational component provided by the Arkansas Department of Health
that includes:
a refusal to vaccinate statement,
a statement of understanding that at the discretion of the Arkansas Department
of Health the non-immunized child/individual shall be removed from daycare,
school, college or univers