Sample Religious Vaccination Exemption

Include 1or more specified vaccinations. If all, use the following:

1st paragraph:
To whom it may concern:

As (a) parent \s, based on my\our personal religious beliefs,
I \we object to the following vaccination , including but not
limited to, DTaP\DTP, HepB, Hib,
MMR, Polio, Varicella, for my\our child___________________.

2nd paragraph
State your personal religious beliefs. The following words are acceptable to the Illinois Department of Public Health:
higher power
prayer
scripture
spiritual belief

Date the letter and sign it. Keep a copy for your files.

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