In the landscape of mandatory vaccinations for school attendance, the HES 113 form emerges as a critical document for those seeking an exemption on religious grounds within the state of Montana. This form serves as an affidavit, enabling students or their guardians to declare that immunization against diseases such as diphtheria, pertussis (whooping cough), tetanus, polio, rubella, mumps, and measles contradicts their religious beliefs. However, the path forged by this declaration is lined with responsibilities and potential legal repercussions. Firstly, signatories are cautioned against false claims, with penalties including fines up to $500 or imprisonment for up to 6 months. Secondly, the form highlights the conditions under which an exempt student might be excluded from school during outbreaks of the aforementioned diseases, thereby emphasizing public health concerns. Lastly, it mandates the annual renewal of the affidavit, ensuring that exemptions remain a deliberate choice and that records are up-to-date. By encapsulating both the rights to religious freedom and the obligations to communal health safety, the HES 113 form plays a pivotal role in balancing individual liberties with public welfare imperatives.
| Question | Answer |
|---|---|
| Form Name | Form Hes 113 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | HES_113_religio us_exemp affidavit immunization print out form |
AFFIDAVIT OF EXEMPTION ON RELIGIOUS GROUNDS FROM
MONTANA SCHOOL IMMUNIZATION LAW AND RULES
Student’s full name |
Birth Date |
Age |
Sex |
School___________________________________
If student is under 18, name of parent, guardian, or other person responsible for student’s care and custody:
________________________________________________________________________
Street address and city:
__________________________________________________________
Telephone: (home) |
(work)_______________________ |
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I, the undersigned, swear or affirm that immunization against diphtheria, pertussis (whooping cough), tetanus, polio, rubella, mumps and measles is contrary to my religious tenets and practices.
I also understand that:
(1)I am subject to the penalty for false swearing if I falsely claim a religious exemption for the
(2)In the event of an outbreak of one of the diseases listed above, the
(3)A new affidavit of exemption for the above student must be signed, sworn to, and
notarized yearly and kept together with the State of Montana Certificate of Immunization (HES- 101) in the school’s records.
____________________________________
Signature of parent, guardian, or other person responsible for the above student’s care and
custody; or of the student, if 18 or older
______________________________
Date
Subscribed and sworn to before me this _______ day of _________, __________.
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______________________________________ |
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Signature: Notary Public for the State of Montana |
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_________________________________________ |
SEAL |
Print Name: Notary Public for the State of Montana |
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Residing in _________________________ |
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My commission expires ______________ |