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Georgia Immunization Exemption Affidavit

This document is an affidavit of religious objection to immunization. It states that the parent or legal guardian of Kennedi DeAmber Clark objects to vaccinating their child based on religious beliefs. It acknowledges that Georgia law requires certain vaccinations for school attendance but asserts the objections are religious and not based on personal philosophy. It also notes that the child could be excluded from school during disease outbreaks even with religious exemption. The parent or guardian and notary public must sign to affirm the religious objection.

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441 views1 page

Georgia Immunization Exemption Affidavit

This document is an affidavit of religious objection to immunization. It states that the parent or legal guardian of Kennedi DeAmber Clark objects to vaccinating their child based on religious beliefs. It acknowledges that Georgia law requires certain vaccinations for school attendance but asserts the objections are religious and not based on personal philosophy. It also notes that the child could be excluded from school during disease outbreaks even with religious exemption. The parent or guardian and notary public must sign to affirm the religious objection.

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DEV
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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AFFIDAVIT OF RELIGIOUS OBJECTION TO IMMUNIZATION

personally appeared before the undersigned notary public and


swore or affirmed as follows:

1. I am the parent or legal guardian of Kennedi DeAmber Clark (name of minor child).

2. I understand that the Georgia Department of Public Health requires children to obtain the following
vaccinations before being admitted to a childcare facility or school: diphtheria; haemophilus influenzae
type B (not required on or after the fifth birthday); hepatitis A; hepatitis B; measles; meningitis; mumps;
pertussis (whooping cough); pneumococcal (not required on or after the fifth birthday); poliomyelitis;
rubella (German measles); tetanus; and varicella (chickenpox).

3. I understand that the Georgia Department of Public Health has determined that these vaccinations are
necessary to prevent the spread of dangerous diseases among the children and people of this State; that
the required vaccinations are safe; that a child who does not receive these vaccinations is at risk of
contracting those diseases; and that a child who does not receive those vaccinations is at risk of
spreading those diseases to me, to other children in the childcare facility or school, and to other persons.

4. I sincerely affirm that vaccination is contrary to my religious beliefs, and that my objections to vaccination
are not based solely on grounds of personal philosophy or inconvenience.

5. I understand that, notwithstanding my religious objections, my child may be excluded from childcare
facilities or schools during an epidemic or threatened epidemic of any disease preventable by a
vaccination required by the Georgia Department of Public Health, and that my child may be required to
receive a vaccination in the event that such a disease is in epidemic stages.

This day of , 20 .

Parent or Legal Guardian (Printed) Parent or Legal Guardian (Signature)

Name of Child/Student (Printed)

Sworn and subscribed before me this day


of , 20 .

Notary Public
My commission expires

DPH Form 2208 [5.2015]

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