Form Hes 113 – Fill Out and Use This PDF

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)_______________________

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 above-named student [i.e. a fine of up to $500, up to 6 months in jail, or both (Sec. 45-7-202, MCA)];

(2)In the event of an outbreak of one of the diseases listed above, the above-exempted student may be excluded from school by the local health officer or the Department of Public Health and Human Services until the student is no longer at risk for contracting or transmitting that disease; and

(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 _________, __________.

	______________________________________
	Signature: Notary Public for the State of Montana
	_________________________________________
SEAL	Print Name: Notary Public for the State of Montana
	Residing in _________________________
	My commission expires ______________

HES-113 (12/2011)