Editing previous response:

Please fix the highlighted areas below before submitting.

Statement of Exemption from Immunizations

Please complete the form below. Required fields marked with an asterisk *

Under the Louisiana Revised Statutes 17:170 Sec E, I ______________________________*

Parent/Guardian's Full Name

Answer required for "Under the Louisiana Revised Statutes 17:170 Sec E, I ______________________________"

parent/guardian of _______________________________*

Student's Full Name

Answer required for "parent/guardian of _______________________________"

I am requesting an exemption from immunization requirements for my child based on medical, religious, or philosophical reasons.

I understand that, in the event of an outbreak of a vaccine-preventable disease at the school or facility my child attends, school administrators—following guidance from the Office of Public Health—may exclude my child from attending until the incubation period has passed or until I provide proof of immunization.

Name of School:

HIGHLAND BAPTIST CHRISTIAN SCHOOL

Signature*

Signature Required

____________________________________________________________________

Signature of Administrator

__________________________

Date

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"