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 university during a vaccine-preventable disease outbreak, and  the non-immunized child/individual shall not return until the disease outbreak has been resolved and the Arkansas Department of Health approves his/her return. Choose ONE of the following reasons for your exemption request: Medical [ ] Must also attach a Physician’s Letter Non-Medical [ ] Religious or [ ] Philosophical Child's/Student's FULL Name: First____________________Middle_________________Last________________________ Street Address_________________________City______________County____________ State____ Zip________ Date of Birth____-____-____ Race___ Sex___ Grade____ For college/university student age 18 years or older: Daytime Phone (_____) _____-_______ E-mail____________________________ College/University - School - Daycare Information: Name_________________________________School District Name________________ Street Address_________________________City______________County____________ Zip_________ Date Enrolled (2009-2010 School Year) ____ ____, 20____ Month Day Year Check ONE: [ ] Daycare [ ] Kindergarten [ ] Middle [ ] Sr. High [ ] Preschool [ ] Elementary [ ] Jr. High [ ] College Parent/Legal Guardian's FULL Name: (Not necessary, if college/university student age 18 years or older) First___________________Middle____________________Last______________________ Street Address__________________________________City________________________ County______________________State_____Zip__________ Daytime Phone (_____) _____-_______ E-mail_____________________________ 3 Refusal to Vaccinate Select from the following list, the vaccine(s) that you do not want your child or self to receive. [ ] DTaP (Diphtheria, Tetanus & Pertussis) [ ] Prevnar (Pneumococcal conjugate) [ ] Hepatitis B [ ] Td (Tetanus, Diphtheria) [ ] Hib (Haemophilus Influenzae Type b) [ ] Tdap (Tetanus, Diphtheria & Pertussis) [ ] MMR (Measles, Mumps & Rubella) [ ] Varicella (Chickenpox) [ ] Polio I have received and reviewed the medical information from the Centers for Disease Control and Prevention discussing the risks and benefits of vaccination. I understand the following:  The purpose of and the need for the recommended vaccine(s).  The risks and benefits of the recommended vaccine(s).  If not receiving the vaccine(s), the consequences may include:  contracting the disease the vaccine should prevent,  transmitting the disease to others, or  the need to stay out of daycare, school, college or university during a disease outbreak.  I may contact the Arkansas Department of Health, at (501) 661-2169, for answers to all of my questions regarding the recommended vaccine(s).  That I may reconsider and accept vaccination anytime in the future. The Arkansas Department of Health, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention all strongly recommended that the vaccine(s) be given. I have decided to decline the vaccine(s) recommended, as indicated above, and have checked the appropriate box(es) for the vaccine(s) being declined. Under penalty of law, I affirm that I have received and reviewed the enclosed medical information and the risks associated with my child/me not being vaccinated as stated in this information and that I still request an exemption from the vaccine(s). Signature_______________________________________________ Parent/Guardian or College/University Student 4 Statement of Understanding I have signed the statement of refusal to vaccinate. I understand that at the discretion of the Arkansas Department of Health any non-immunized individual shall be removed from the facility for which he/she is attending during a vaccine-preventable disease outbreak. I further understand that the individual shall not return to the facility until the outbreak has been resolved and the Arkansas Department of Health approves his/her return. Signature______________________________________________ Parent/Guardian or College/University Student Release of information will be provided only to the custodial parent/guardian or person who completes this application – according to the notarized signature. Notary Public State of____________________________ County of__________________________ On this the_____day of____________________, 20____, before me, _________________________, the undersigned notary, personally appeared _____________________________________________ known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. ______________________________________ Notary Public My commission expires___________________________________ Seal Mail to: Arkansas Department of Health Exemptions 4815 West Markham #48 Little Rock, AR 72205 04/09