MASCONOMET REGIONAL SCHOOL DISTRICT

REQUEST FOR EXEMPTION OF IMMUNIZATIONS

Dear Parent or Guardian,

As you are requesting a waiver for your child because of medical or religious beliefs, we would like to make you aware of your responsibilities and the consequences of waiving immunizations for DPT, polio, measles, mumps, rubella, hepatitis B and chicken pox. In accordance with the Isolation and Quarantine Regulations of the Mass. Department of Public Health*, your exempted child may be excluded from the school under certain circumstances. In the event of an exposure to one of the vaccine preventable diseases in the school, your child will have to be excluded from school until one incubation period beyond the onset of the final case.

It is difficult to assign a number of days, weeks, etc., to these quarantine periods as we are never sure how many cases will occur. However, the rationale for this practice is to protect your child, other children and staff in the school. The required quarantine period will be determined by our school physician.

Please complete the appropriate section below and return it to the Senior High School Nurse’s Office, for inclusion in your child’s health record. If you have any questions, please call my office at 887-2323, ext. 6116.

Sincerely,

Karen Flom Rn, BSN, NCSN

MASSACHUSETTS REQUEST FOR RELIGIOUS EXEMPTION FROM IMMUNIZATION

To_______________________________________________________________________________________________

(Principal of Senior High School)

As a parent/guardian of___________________________________________, a minor enrolled in the public schools, I request that said minor be exempt from the immunization requirements on religious grounds in accordance with the provisions of Chapter 76, Section 15, General Laws of Massachusetts as amended by Chapter 285 of the Acts of 1971.

Signed_______________________________________________________Parent/Guardian Date________________________________________

Address_________________________________________________________________________________________________________________

(street) (town) (zip code)

MASSACHUSETTS REQUEST FOR RELIGIOUS EXEMPTION FROM PHYSICAL EXAMINATION

To_______________________________________________________________________________________________

(Principal of Senior High School)

As a parent/guardian of___________________________________________, a minor enrolled in the public schools, I request that said minor be exempt from physical exam requirements on religious grounds in accordance with the provisions of Chapter 71, Section 57, General Laws of Massachusetts.

Signed_______________________________________________________Parent/Guardian Date________________________________________

Address_________________________________________________________________________________________________________________

(street) (town) (zip code)

MASSACHUSETTS REQUEST FOR MEDICAL EXEMPTION FROM IMMUNIZATION

To_______________________________________________________________________________________________

(Principal of Senior High School)

I request that ____________________________________________ a minor enrolled in public schools, be exempt from the immunization

(child’s name)

requirements as set forth by Massachusetts General Laws for the medical reason(s) indicated below.

Signed_______________________________________________________Parent/Guardian Date________________________________________

Address_________________________________________________________________________________________________________________

(street) (town) (zip code)

MD Signature___________________________________________________________Date_________________________________

Reason(s) for exemption________________________________________________________________________________________