STATEMENT OF IMMUNIZATION HISTORY;
WAIVER; RULES - INDIANA CODE §20-34-4-5
(a) Each school shall require the parent of a student who has enrolled in the school to furnish not later than the first day of school a written statement of the student's immunization, accompanied by the physician's certificates or other documentation, unless a written statement of this nature is on file with the school.
(b) The statement must show, except for a student to whom IC 20-34-3-2 or IC 20-34-3-3 applies, that the student has been immunized as required under section 2 of this chapter. The statement must include the student's date of birth and the date of each immunization.
VACCINATION EXEMPTION PURSUANT TO INDIANA CODE §20-34-3-2
(a) Except as otherwise provided, a student may not be required to undergo any testing, examination, immunization, or treatment required under this chapter or IC 20-34-4 when the child's parent objects on religious grounds. A religious objection does not exempt a child from any testing, examination, immunization, or treatment required under this chapter or IC 20-34-4 unless the objection is:
(1) made in writing;
(2) signed by the child's parent; and
(3) delivered to the child's teacher or to the individual who might order a test, an exam, an immunization, or a treatment absent the objection.
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VACCINE EXEMPTION FORM
I, as the parent, guardian or person in loco parentis of the child named below, hereby certify that the administration of any vaccine or other immunizing agents is contrary to our personal religious beliefs.
Measles
Diphtheria
Mumps
Tetanus
Rubella
Pertussis
Polio
Haemophilus influenzae type b
Hepatitis B
Varicella
Hepatitis A
Other
This is pursuant to my right to refuse vaccination on the grounds that vaccinations conflict with my religious beliefs. Pursuant to Indiana statute, I am signing and providing this statement to our child’s school administrator or operator of the group program pursuant to IC § 20-34-3-2.
