53-05A: Oregon Certificate of Immunization Status

53-05A PDF Details

Parent, guardian, child at least 15 years of age, medical provider or county health department staff person may sign to verify vaccinations received.

Medical exemption: a medical exemption requires a form completed and signed by a licensed physician or local health department.

Nonmedical exemption: I understand my child may be excluded from school or child care if there is a case of disease that could be prevented by vaccine.

Signature: the parent or guardian signature is a sworn statement that the child's record is accurate.

Re-signing: every time you add on to your child's information you need to resign the form.