Statement of Exemption:

Under Louisiana Revised Statutes 17:170 Sec E, I hereby claim exemption from the immunization requirement for Medical reasons.

(Physician statement for dissent for medical reasons attached.)

I understand that in the event of an outbreak of a vaccine-preventable disease at the location of the educational institution or facility the student attends, the administrators of the educational institution or facility, upon the recommendation of the office of public health, may exclude the student from attendance until the incubation period has expired or I present evidence of immunization.

_____________________________ Student signature

_____________________________ Date

_____________________________ Parent or Guardian’s signature (if required)