Arizona Religious Beliefs Form PDF Details

In Arizona, the intertwining of public health requirements with individual freedoms manifests prominently through the Religious Beliefs Exemption Form, a pivotal document created by the Arizona Department of Health Services (ADHS). This form caters specifically to preschools and childcare facilities, establishing a procedural pathway for parents or guardians who, due to their religious convictions, choose to exempt their children from the state-mandated immunizations that prevent infectious diseases such as diphtheria, tetanus, pertussis (whooping cough), polio, measles, mumps, rubella, Hib, hepatitis B, hepatitis A, and varicella (chickenpox). ADHS delineates this option while simultaneously advocating for vaccination as a critical preventative measure against these diseases, which can lead to severe health complications or even death. The form requires guardians to mark and initial against the specific immunizations they are opting out of on behalf of their child, following an acknowledgment of the potential health risks involved. Additionally, it outlines the consequences of such a decision, including the possibility of the child being barred from attending childcare during outbreaks of vaccine-preventable diseases. This documentation, reflective of a commitment to respecting parental rights and religious freedoms, also underscores the importance of informed decision-making regarding public health and safety.

QuestionAnswer
Form NameArizona Religious Beliefs Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesarizona religious exemption, religious exemption form az, religious exemption az, religious exemption form for vaccines

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Arizona law requires that preschools and child care facilities use this official ADHS form to document a religious beliefs exemption to immunization.

Religious Beliefs Exemption Form

For Child Care, Preschool and Head Start Programs

Arizona Department of Health Services (ADHS) strongly supports immunization as one of the easiest and most effective tools in preventing diseases that can cause serious illness and even death. ADHS also respects the rights of parents who are raising their child in a religion whose teachings are in opposition to immunization to make the decision not to vaccinate their child.

Place an “X” in the box to the left of the disease(s) listed to exempt your child from the vaccine. Initial and date the box on the right.

 

 

 

Diphtheria (DTaP, Tdap, Td): I have been informed that by not receiving this vaccine, my child may be at increased risk

Initials___________

 

 

 

of developing diphtheria if exposed to this disease. Serious symptoms and effects of this disease include: heart failure,

 

 

 

 

 

 

 

paralysis (can’t move parts of the body), breathing problems, coma, and death.

Date____________

 

 

 

 

 

 

Tetanus (DTaP, Tdap, Td): I have been informed that by not receiving this vaccine, my child may be at increased risk of

 

 

 

 

developing tetanus if exposed to this disease. Serious symptoms and effects of this disease include: “locking” of the jaw,

Initials___________

 

 

 

 

 

 

 

difficulty in swallowing and breathing, seizures (jerking and staring), painful tightening of muscles in the head and neck,

Date____________

 

 

 

 

 

 

and death.

 

 

 

 

 

 

 

 

 

Pertussis (Whooping Cough) (DTaP, Tdap): I have been informed that by not receiving this vaccine, my child may be at

Initials___________

 

 

 

increased risk of developing pertussis (whooping cough) if exposed to this disease. Serious symptoms and effects of this

 

 

 

 

 

 

 

disease include: severe coughing fits that can cause vomiting and exhaustion, pneumonia, seizures (jerking and staring),

Date____________

 

 

 

 

 

 

brain damage, and death.

 

 

 

 

 

 

 

 

 

Polio: I have been informed that by not receiving this vaccine, my child may be at increased risk of developing polio if

Initials___________

 

 

 

exposed to this disease. Serious symptoms and effects of this disease include: paralysis (can’t move parts of the body),

 

 

 

 

 

 

 

meningitis (infection of the brain and spinal cord covering), permanent disability, and death.

Date____________

 

 

 

 

 

 

 

 

 

 

 

Measles, Mumps, Rubella (MMR): I have been informed that by not receiving this vaccine, my child may be at increased

 

 

 

 

 

 

 

 

risk of developing measles, mumps, and/or rubella if exposed to these diseases. Serious symptoms and effects of

 

 

 

 

measles include: pneumonia, seizures (jerking and staring), brain damage, and death. Serious symptoms and effects of

Initials___________

 

 

 

 

 

 

mumps include: meningitis (infection of the brain and spinal cord covering), painful swelling of the testicles or ovaries,

Date____________

 

 

 

sterility, deafness, and death. Serious symptoms and effects of rubella include: rash, arthritis, and muscle or joint pain. If a

 

 

 

 

 

 

 

woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth

 

 

 

 

defects such as deafness, heart problems, and brain damage.

 

 

 

 

Haemophilus Influenza type b (Hib): I have been informed that by not receiving this vaccine, my child may be at

 

 

 

 

 

 

 

 

increased risk of developing Hib if exposed to this disease. Serious symptoms and effects of this disease include:

Initials___________

 

 

 

meningitis (infection of the brain and spinal cord covering), pneumonia, severe swelling in the throat that makes it hard to

Date____________

 

 

 

 

 

 

 

 

 

 

breathe, infections of the blood, joints, bones, and covering of the heart, and death.

 

 

 

 

 

 

 

 

 

Hepatitis B: I have been informed that by not receiving this vaccine, my child may be at increased risk of developing

Initials___________

 

 

 

hepatitis B if exposed to this disease. Serious symptoms and effects of this disease include: jaundice (yellow skin or

 

 

 

 

 

 

 

eyes), life-long liver problems, such as scarring and liver cancer, and death.

Date____________

 

 

 

 

 

 

 

 

 

 

 

Hepatitis A: I have been informed that by not receiving this vaccine, my child may be at increased risk of developing

Initials___________

 

 

 

hepatitis A if exposed to this disease. Serious symptoms and effects of this disease include: jaundice (yellow skin or

 

 

 

 

 

 

 

eyes), “flu-like” illness, hospitalization, and death.

Date____________

 

 

 

 

 

 

 

 

 

 

 

Varicella (Chickenpox): I have been informed that by not receiving this vaccine, my child may be at increased risk of

Initials___________

 

 

 

developing varicella (chickenpox) if exposed to this disease. Serious symptoms and effects of this disease include: severe

 

 

 

 

 

 

 

skin infections, pneumonia, brain damage, and death.

Date____________

 

 

 

Due to my religious beliefs, I request an exemption for my child from the required vaccine doses selected above. I am aware that if I change my mind in the future, I can rescind this exemption and obtain immunizations for my child.

Initials_________________________

∙I am aware that additional information about vaccine preventable diseases, vaccines and reduced or no cost vaccination services is available from my local county health department and Arizona Department of Health Services (www.azdhs.gov/phs/immun/).

∙I am aware that in the event the state or county health department declares an outbreak of a vaccine-preventable disease for which I cannot provide proof of immunity for my child, he or she may not be allowed to attend child care until the risk period ends, which may be 3 weeks or longer.

Child’s Name ______________________________________________________ Date of Birth (month/day/year)__________________________

Parent/Guardian Signature____________________________________________ Date (month/day/year)_________________________________

ADHS Immunization Program Office

http://www.azdhs.gov/phs/immunization/

July 1, 2013 (rev: 9/1/18)

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1. You should fill out the religious beliefs exemption properly, hence be mindful while working with the areas comprising these blank fields:

arizona vaccine exemption form 2021 writing process clarified (portion 1)

2. After the last section is filled out, proceed to enter the relevant details in these: Polio I have been informed that by, Initials Date, Hepatitis B I have been informed, Initials Date Initials Date, Due to my religious beliefs I, I am aware that additional, and Childs Name Date of Birth.

Writing segment 2 in arizona vaccine exemption form 2021

Be extremely mindful while filling out I am aware that additional and Initials Date Initials Date, since this is where many people make some mistakes.

3. Completing Childs Name Date of Birth, and ADHS Immunization Program Office is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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