r Date of Birth
Name
lN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAy BE SUEJECT TO EXCLUSION FROM SCHOOL AND TO OUARAilnNE. sl SE PBESEIiITA Ur{ BBOIE
OE LA
EilTERTEOAD, E8 POSALE OUE A LAS PEBSONAS flETITAS SE LES POilGA
E
{ CUAFEilTEflA O SE LES EXCLUYA
DE LA
ESCUELA
condition ol the above named person is such lhat immunizalion would endanger lite or health or is medically contraindicatsd due to olher modical conditions. EXEI.ICIoN POR BAZONES IEDrcAS: Et estado de salud de la persona aniba citada es tal que la vac1fiEci6n significa un liesgo para su salud o incluso su vida; o
UEDrcAL Ef,EMPTON: The physicat
bien,las veunas esliin contrairdhadas debido e otros probhnas de salud. tled,o8,l
L. Signed
,@
ex*tption to the following vwine(sl: d*fiw adia a b(s) siguiut/€l(s) w(s|
ex,,,Ec&t por nmneg
Date (Feclla)
(Flrma)
RELIGIOUS EXEIIIPTION: parent or guardian of the above named person or the person himself/herself is an adflerent to a religious beliet opposed to immunizations. EXENC|6N POn ilOnVOS RELIGIOSOS: El padre o tutor de la persona ariba cihda, o la persona misma, p€rtenec€ a una religi6n que se opon€ a la inmunizaci6n. Seligious exanptton to tte fotlowing vaeine(s): E tMa Fr ,,Edita {€figtbrE' e b(s) sigaf,,ltqq vear$(s) :
- --'piiJir
Date (F€cha)
(Firma) SiSned -
r
(Padre, $!or, estldianb EmencFadoo consenlifldgnto dol
tmor)
PEHSONAL EXEMPTTON: parent or guardian ol lhe above narned person or the person himself/herself is an adheront to a personal beliel opposed to immunizations.
EXENCloil FOR CREET{CIAS PERSONALES: las inmunizacilin.
creencias personalos del padrc o tutor d€ la persona aniba citada, o la p€tsona rniEma, se oporEo a la
-
Pe6onal cxem$on to he following vaccine(s):
b@din
(Finna)-- --'pirerit
por
crr6rcl* partoiekg
de raf6,
s!r!*rn
e(s,l
Y*ffi{s):
Date (Fecha)
Signed
r
(Padts. lGor. €studrarE mandrrado o corE€nrimic5lio dd nlelw,
Table 2. TIMETABLE FOR IMPLEMENTATION OF BEOUIHEMENTS FOH SELECTED IMMUNIZATIONS FOH GRADES K.12
-
Below is a partial chart ol specific immunization requirements. By 2@&-2007, the measles, mumps ard rubella (MMH) vaccine (second dose) will be required tor K-12. By 2012-2A13, the varicella (VAR) vaccine will be required tor grades K-12. The school year is July 1 through June 30. ln Table 2, aller a vaccine is required for grades K-12, it is no longer Shown, but the requirem€nts listed in Table 1 continue to apply.
Grade Levd School Year K
I
2
3
4
5
I
t0
fi
12
MMR*2 MMR#2 MMR*2
MMH#2 VAR
MMR#2
MMR#2
MMR#2
VAR
VAR
VAR
VAR
VAFI
VAR
VAH
VAi
VAR
VAR
VAR
VAH
VAR
VAFI
VAB
VAFI
VAR
VAR
V/dR
VAFI
VAB
VAR
VAR
VAB
VAR
VAH
VAB
VAR
VAR
VAH
VAR
VAR
VAR
VAH
VAH
VAR
VAR
VAR
VAR
VAR
VAR
VAR
VAH
VAR
VAR
VAB
VAR
MMR#2 VAR
MMR#2 VAR
VAR
VAH
VAR
VAR
VAR
VAB
VAR
VAR
VAR
2010-2011
VAB
VAR
201',t-?o12
VAR
2412-2o13 VAR required
VAR
MMB#2 MMR#2 VAR
VAR
e00G-2007 MmR required
MMH*2 VAB
MMR#2
MMR#2 VAR
MMR#2
VAR
2007-2008
VAR
VAH
2008-2009
VAH
20@-2010
for K-12
I
MMR*2 MMR#2
MMRtrz VAR
MMR#2 VAR
lor K-l2
7 MMR#2
Mtt R#2 MMR#2 VAR VAR
2005-2006
e
MMR#2
MMH#2 MMR#2
VAH
