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Would you like a conference with the school nurse No Yes Parent/Guardian Signature Date Immunization Exemption Form As a parent/guardian of Student name In grade and date of birth I am requesting a waiver for the following immunizations All required immunizations Specific immunizations DTAP Varicella I/OPV MMR I understand that in the case of an outbreak of the specific disease for which my child is not protected my child will be kept out of school and school activities. Exemption from...

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