Immunization Waiver Form - Michigan
CAPITOL VIEW BUILDING • 201 TOWNSEND STREET • LANSING, MICHIGAN 48913
www.michigan.gov • 517-373-3740 DCH-1272 (01 /1 1)
IMMUNIZATION WAIVER FORM
INSTRUCTIONS TO PARENTS OR GUARDIAN S:
Vaccine-preventable diseases are still wit h us. Immunizations are one of the most cost-effective measures to protect chil d r en from
harmf ul dis eases and even death. A high proportion of c hildren must be i mmunized to prevent outbreaks of disease in school settings
and other places where children wor k and play closel y together.
Sections 9208 and 9211 of the Michigan Public Health Code require that a parent, guardian, or person in loco parentis applying to
have a c hild r e gistered for the first time in a Michigan school and/or in 6
grade, or in a program of group residence, care, or camping
in this state shall present to officials at the time of re gistration or no t la te r than the first day of school or program enrollment, a
certificate of immuniza tion verifying that the child has been vacc inated against diphther ia , tetan us, p e rtussis, measle s, mumps, rubella,
polio, hepatitis B, and varicella (chickenpox). Pneumococcal conjugate and Haemophilus influenzae type b vaccines are also require
for preschool-aged children. Meningoco ccal vaccine is required for children 11 years of age or older who are in the 6
grade or newly
enrolle d in the district.
A parent or guardian wishing to exempt his or her child from a particular vaccination must pro vide a written statement i ndicating the
religious or philosophical objections to the vacci nation(s). A child who has been exempted from a vaccinatio n is considered
susceptible to the disease or diseases for which the vaccinatio n offers protection. The child may be subject to exclusion from the
schoo l or p r o gram, i f the local and/or state public health authorit y advises excl usion as a disease control measure.
B y si gni n g thi s wai ve r , you ac knowle d ge that yo u are placing your child and others at risk of serious i llness should he or she contract
a disease that could have been p revented throu gh proper vaccination.
ALL INFORMATION MUST BE FILLE D IN BE L OW.
I object to having my child, , born , immu nized with the
vaccines I have checked below: (First & Last Nam e) (Birth Date)
DTaP, DT, Td, Tdap (Diphtheria, Tetanus, Pertussis)
Haemophilus influenzae type b
MMR (Measles, Mumps, Rubella)
Chi l d's Addre ss Telephone:
If different from parent/guardian
Parent or Guardi an's Si gnature Date Signed
Preschool Program or Licensed Day Care Center OR School Name (Required)
File in the child's permane nt rec ord and send a copy to you r local health department.
DCH-0716 AU THORITY: P.A. 368 of 1 978, Part 92 Rev. 3/2011
Immunization Waiver Form - Michigan PDF
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