Personal Beliefs Exemption Form

Effective January 1, 2014, parents who want to exempt their child from one or more required immunizations because of their personal beliefs must provide to the school or child care facility:

    1)  A letter or affidavit requesting an exemption that states that the required immunization(s) are contrary to their beliefs;
    2)  A statement signed and dated by a health care practitioner and parent indicating that the practitioner has provided, and the parent has received, information about the benefits and risks of immunizations and the risks of vaccine-preventable diseases.

Parents and health care practitioners must use the one-page form that meets all the above requirements developed by the California Department of Public Health and available from many schools and health care practitioners.

Most children with exemptions have received some of their required vaccines. In addition to the vaccines for which an exemption is being requested, parents must show the school or child care facility a valid record of which of the immunizations required for school or child care that their child has received.


A partir del 1 enero de 2014, los padres que quieren eximir a sus hijos de una o más vacunas requeridas por sus creencias personales deben proveer a la escuela o guardería:

    1) Una carta o una declaración jurada solicitando una exención que indica que la(s) vacuna(s) requerida (s) son contrarias a sus creencias;
    2) Una declaración firmada y fechada por un profesional médico y los padres indicando que el profesional médico ha facilitado, y el padre ha recibido información acerca de los beneficios y riesgos de las vacunas y los riesgos de las enfermedades prevenibles por vacunas.