Arizona Religious Beliefs Form – Fill Out and Use This PDF

The Arizona Religious Beliefs Exemption Form is a document required by the Arizona Department of Health Services for parents who choose to exempt their children from mandatory vaccinations based on religious convictions. It is used for preschools, child care facilities, and Head Start programs across Arizona. Parents must initial next to each specific vaccine they are opting out of, confirming they understand the health risks involved. Fill out this form by clicking the button below.

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Arizona Religious Beliefs Form PDF Details

The Arizona Religious Beliefs Exemption Form was created by the Arizona Department of Health Services (ADHS) to provide a lawful process for parents whose religious convictions are in conflict with the state's mandatory vaccination requirements. The form is required for enrollment in any licensed preschool, child care facility, or Head Start program in Arizona.

The exemption form covers all vaccines mandated by Arizona for young children. Parents or guardians must initial next to each vaccine they wish to decline. The vaccines listed include the DTaP combination (diphtheria, tetanus, pertussis), poliovirus (IPV), MMR (measles, mumps, rubella), Haemophilus influenzae type b (Hib), hepatitis B, hepatitis A, and varicella (chickenpox). Each initial confirms that the parent has received information about the disease and understands the health risks of not vaccinating.

By completing the form, parents acknowledge that vaccine-preventable diseases can result in serious medical complications including hospitalization, long-term disability, or death. The ADHS advocates for vaccination as the most effective protection against these illnesses, but also recognizes the right of parents with sincere religious beliefs to opt out through this documented process.

One important consequence of filing the exemption is that the child may be excluded from attending child care or preschool during an active outbreak of a vaccine-preventable disease. This exclusion policy applies to protect other children in the facility, including infants too young to be vaccinated and children with medical contraindications to vaccines. The exclusion may last several days to several weeks depending on the outbreak timeline.

After the form is completed, it must be submitted to and kept on file at the child care facility or preschool. The facility is required to include this form in the child's official enrollment records. If the child transfers to a new facility, a fresh copy of the exemption form may be required. Parents are advised to keep a personal copy as well.

Arizona provides the religious belief exemption as a recognized legal right under state law, while continuing to recommend vaccination through its public health programs. Parents who are considering an exemption are encouraged to consult with their pediatrician to review the risks before making a final decision.

Question	Answer
Form Name	Arizona Religious Beliefs Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	arizona religious exemption, religious exemption form az, religious exemption az, religious exemption form for vaccines

How to Edit Arizona Religious Beliefs Form Online for Free

You can fill out this religious beliefs exemption form easily using our PDFinity® editor. Our expert team works continuously to improve the tool and make it simple and reliable for every user. Follow these steps to complete and save your form accurately.

Step 1: Open the tool by clicking the "Get Form Button" at the top of this page.

Step 2: Use the PDF editor to fill in required fields, add text, adjust existing content, upload images, and add your electronic signature.

For you to fill out this PDF document, be sure to type in the information you need in each blank field:

1. Fill out the first section of the religious beliefs exemption carefully, paying attention to these fields:

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

2. After the first section, proceed to enter information in these fields: 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

Take extra care when filling out the "I am aware that additional" and "Initials Date Initials Date" fields. Errors in these sections are the most common mistakes people make when completing the form.

3. Completing "Childs Name Date of Birth" and the ADHS Immunization Program Office fields is required before you can finalize the form. Do not leave these blank.

Step no. 3 for completing arizona vaccine exemption form 2021

Step 3: Before finishing, review every field to confirm the information is correct. When you are satisfied, click "Done." Sign up for a FormsPal account to save the form and return to edit it at any time. We never sell or share the information you enter on FormsPal.

Where to Submit the Completed Arizona Exemption Form

After completing the form, submit it directly to the child care facility, preschool, or Head Start program where your child will be enrolled. The facility is required to keep this document on file as part of the child's enrollment records. Do not mail the form to ADHS directly. The child's school or child care center is the correct point of submission.

If you have questions about the submission process, contact your child's enrollment coordinator at the facility. You can also reach the ADHS Immunization Program Office, whose contact information is printed on the official form.

When Is the Arizona Religious Beliefs Form Needed?

The form must be submitted at or before the time of enrollment in a licensed Arizona preschool, child care center, or Head Start program. It is part of the required health documentation package for all new students. If your child changes facilities, the new school may ask for a current copy of the exemption form rather than accepting a transfer of the record from the previous location.

If your views change and you decide to vaccinate your child, notify the facility so that the exemption status can be updated. The facility will need to record the updated vaccination information and remove the exemption filing from the child's active record.

Other Vaccine Exemption and Health Forms

If you need a vaccine exemption form for a different state, the following forms are available on FormsPal:

For other health documentation that may be required for Arizona child care enrollment, you may also need the Child and Adolescent Health Form.