Kentucky Parent or Guardian Declination Immunization
This file is for parents or guardians in Kentucky who wish to decline required immunizations for their child on religious grounds. It provides a sworn statement format along with serious health risks associated with each disease. Use this form to officially document the decision for immunization exemption.
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How do I fill this out?
To fill out this form, start by indicating the specific immunizations you are declining for your child. Next, provide your initials and date beside each selected vaccine. Finally, complete the parent signature section and have it notarized.
How to fill out the Kentucky Parent or Guardian Declination Immunization?
1
Read the instructions and disease information carefully.
2
Place an 'X' next to each immunization you are declining.
3
Initial and date next to your selections.
4
Provide your child's information at the beginning of the form.
5
Sign the form and have it notarized.
Who needs the Kentucky Parent or Guardian Declination Immunization?
1
Parents concerned about immunization for religious reasons.
2
Guardians who require an official exemption for school enrollment.
3
Families relocating to Kentucky needing proper documentation.
4
Individuals wishing to understand vaccine-related risks.
5
Healthcare providers needing a signed declination form.
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What are the instructions for submitting this form?
To submit this form, please ensure it is fully completed and signed. After signing, submit it to your local health department either by email or fax, or deliver it physically to their office. It is important to keep a copy for your records while following up to confirm receipt.
What are the important dates for this form in 2024 and 2025?
Important dates for the use of this form include the upcoming school year enrollment periods in 2024 and 2025. Be mindful of local health department deadlines regarding immunization compliance. Always check for any updates on relevant health regulations as they may change.
What is the purpose of this form?
This form serves to officially document a parent's or guardian's objections to required immunizations based on religious beliefs. It is a critical tool to ensure that children can attend school and childcare without the health risks associated with mandated vaccines. By completing this form, guardians affirm their commitment to their child's health choices while fulfilling state requirements.
Tell me about this form and its components and fields line-by-line.
- 1. Child's Name: The full name of the child whose immunizations are being declined.
- 2. Child's Date of Birth: The birth date of the child, providing identification.
- 3. Parent Signature: The signature of the parent or guardian submitting the form.
- 4. Notary Public: Space designated for the notary to validate the form.
- 5. Initials and Dates: Places for initials and dates beside each immunization listed.
What happens if I fail to submit this form?
Failing to submit this form may result in your child being unable to attend school or childcare facilities during vaccine-preventable disease outbreaks. It is crucial to adhere to local health mandates by completing and submitting this form accurately.
- School Attendance: Your child may be excluded from school until the issue is resolved.
- Healthcare Compliance: Non-submission could lead to difficulties in receiving healthcare services.
- Legal Implications: There may be legal responsibilities tied to the failure to vaccinate without documentation.
How do I know when to use this form?
- 1. School Enrollment: To enroll a child in school while declining immunizations.
- 2. Childcare Registration: For registering a child in a daycare that requires immunization proof.
- 3. Vaccination Exemption: To formally document a religious exemption from vaccinations.
Frequently Asked Questions
How do I declain an immunization for my child?
Fill out the form provided by checking the applicable immunizations and signing it.
Where can I get this PDF?
You can download the PDF directly from PrintFriendly to get your copy.
Can I edit this PDF online?
Yes, PrintFriendly allows you to edit your PDF documents easily.
Is there a cost to edit this form?
No, editing the form on PrintFriendly is free.
What do I do after filling out the form?
After completion, sign it and have it notarized if required.
Can I share the form electronically?
Absolutely! PrintFriendly provides easy sharing options.
What if I change my mind about the immunization?
You can rescind your objection and obtain immunizations for your child.
How long is this document valid?
The validity is generally until the child reaches the age requirements or changes are declared.
Do I need to submit this form to a health department?
Yes, it's advisable to submit the completed form to your local health department.
Will this exempt my child from all vaccinations?
This form specifically indicates exemptions based on religious beliefs.
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