California Adult Vaccine Exemption

Date School or Governing Authority Address City, State, Zip Code RE: Vaccination Exemption Dear (Name): I am writing to request an exemption from (institution name)‘s immunization requirements based upon my philosophical objections to the practice of immunization. I am claiming this in accordance with California Health and Safety Code Section 120365, which reads as follows: Immunization of a person shall not be required for admission to a school or other institution listed in Section 120335 if the parent or guardian or adult who has assumed responsibility for his or her care and custody in the case of a minor, or the person seeking admission if an emancipated minor, files with the governing authority a letter or affidavit stating that the immunization is contrary to his or her beliefs. This letter serves as my formal request to (institution name) that I be exempt from the required immunizations because this medical practice is contrary to my beliefs. Thank you for your attention to this important matter. If you have any questions do not hesitate to contact me. Sincerely,

Your Name Enclosure: (YOUR STATE) Health and Safety Code Xc: Michael Peabody, Esq., Vice President Seventh-day Adventist Church State Council