(6) Provision for exemption from the immunization program for an enrollee whose parents or legal guardian, because of individual religious
beliefs, reject the concept of immunization. Such a request for exemption
shall be supported by the affidavit herein set forth:
AFFIDAVIT OF RELIGIOUS BELIEF
STATE OF DELAWARE
........................ COUNTY
1.(I) (We) (am) (are) the (parent(s)) (legal guardian(s)) of ..................................................................................................................................................
Name of Child
2.(I) (We) hereby (swear) (affirm) that (I) (we) subscribe to a belief in a relation to a Supreme Being involving duties superior to those arising from
any human relation.
3.(I) (We) further (swear) (affirm) that our belief is sincere and meaningful and occupies a place in (my) (our) life parallel to that filled by the
orthodox belief in God.
4. This belief is not a political, sociological or philosophical view of a merely personal moral code.
5. This belief causes (me) (us) to request an exemption from the mandatory school vaccination program for ....................................................................................................
Name of Child
6. (I) (We) acknowledge that, in the event that the Division of Public Health declares that there is an outbreak of a vaccine preventable disease, or if in the estimation of the Division of Public Health, (my) (our) child has had, or is at risk of having an exposure to a vaccine preventable disease, (my) (our) child shall be temporarily excluded from attendance at the public school, in which case, it will be (my) (our) responsibility, along with the school, to assist (my) (our) child in keeping up with school work, and (my) (our) child shall be authorized to return to school once approved by the Division of Public Health.7. (I) (We) acknowledge that (I) (we) have been given the opportunity to receive from the school district information regarding the medical benefits and risks in choosing whether to have the child participate in the immunization program, and if (I) (we) have not taken that opportunity, it is hereby waived. __________________________________
Signature of Parent(s) or Legal Guardian(s)
SWORN TO AND SUBSCRIBED before me, a registered Notary Public, this __________ day of ____________, _______
(Stamp or Seal)
Notary Public
My commission expires: