California Vaccine Exemption (child) 1

(Date) Parent's Name & Address

To Whom It May Concern, We, the parents of ____________________ , hereby claim exemption from the immunization requirement for Philosophical/Personal reasons, citing California Health & Safety Code 120365 in accordance with Title 17, CCR Section 6051 (2003).

________________________________________ Mother's Signature

_____________ Date

________________________________________ Father's Signature

_____________ Date

California Health and Safety Code Section 120365, 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.