The Arizona Religious Beliefs form is an official document required by state law for preschools and child care facilities. It allows parents to formally request an exemption from immunizations based on their religious beliefs. By completing this form, you affirm your right to make health decisions for your child in accordance with your faith.
To proceed with the exemption process, please fill out the form by clicking the button below.
The Arizona Religious Beliefs form serves as a crucial document for parents who seek an exemption from immunization requirements for their children in preschools and child care facilities. Mandated by Arizona law, this official form from the Arizona Department of Health Services (ADHS) allows parents to formally declare their religious beliefs that oppose vaccinations. While the ADHS emphasizes the importance of immunization as a vital public health measure, it also respects the rights of families to make decisions aligned with their faith. The form requires parents to indicate which vaccines they are opting out of by placing an “X” next to the specific diseases listed, such as diphtheria, tetanus, and measles. Additionally, parents must initial and date each selection, acknowledging the potential health risks associated with not vaccinating their child. This includes serious complications that can arise from diseases like pertussis and polio, which can lead to severe illness or even death. The form also outlines the possibility of rescinding the exemption should parents change their minds in the future, and it provides important information regarding the consequences of an outbreak of vaccine-preventable diseases. By completing this form, parents navigate the balance between their religious convictions and public health responsibilities, ensuring that their child's educational environment aligns with their beliefs.
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,
difficulty in swallowing and breathing, seizures (jerking and staring), painful tightening of muscles in the head and neck,
and death.
Pertussis (Whooping Cough) (DTaP, Tdap): I have been informed that by not receiving this vaccine, my child may be at
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),
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
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.
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
mumps include: meningitis (infection of the brain and spinal cord covering), painful swelling of the testicles or ovaries,
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:
meningitis (infection of the brain and spinal cord covering), pneumonia, severe swelling in the throat that makes it hard to
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
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.
Hepatitis A: I have been informed that by not receiving this vaccine, my child may be at increased risk of developing
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.
Varicella (Chickenpox): I have been informed that by not receiving this vaccine, my child may be at increased risk of
developing varicella (chickenpox) if exposed to this disease. Serious symptoms and effects of this disease include: severe
skin infections, pneumonia, brain damage, and death.
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)
Completing the Arizona Religious Beliefs form is an essential step for parents seeking an exemption from immunization requirements for their child. This process requires careful attention to detail to ensure that all necessary information is accurately provided. Follow these steps to fill out the form correctly.
After completing the form, submit it to your child's preschool or child care facility. They will review the information and process the exemption as required by Arizona law. Keep a copy of the completed form for your records.
What is the Arizona Religious Beliefs form?
The Arizona Religious Beliefs form is an official document required by Arizona law for parents or guardians who wish to exempt their children from certain vaccinations based on their religious beliefs. This form must be used by preschools and child care facilities to ensure compliance with state regulations while respecting the rights of families who choose not to vaccinate for religious reasons.
How do I fill out the form?
To complete the form, you will need to indicate which vaccines you are requesting an exemption for by placing an “X” in the corresponding box. After that, you must initial and date the box to acknowledge that you understand the risks associated with not vaccinating your child. It’s important to provide your child’s name, date of birth, and your signature as the parent or guardian at the end of the form.
What happens if I do not vaccinate my child?
If you choose not to vaccinate your child and have submitted the Religious Beliefs form, it's crucial to understand that your child may face restrictions during outbreaks of vaccine-preventable diseases. If the state or county health department declares an outbreak and your child cannot prove immunity, they may not be allowed to attend child care or preschool until the outbreak risk period has passed, which can last three weeks or longer.
Can I change my mind after submitting the form?
Yes, you can change your mind after submitting the Religious Beliefs form. If you decide to vaccinate your child in the future, you can rescind the exemption. It’s advisable to communicate this change to your child’s school or daycare facility and provide any necessary documentation of the vaccinations received.
Where can I find more information about vaccines and immunization services?
For additional information regarding vaccine-preventable diseases, vaccines, and low-cost vaccination services, you can visit your local county health department or the Arizona Department of Health Services website at www.azdhs.gov/phs/immun/. These resources can help you make informed decisions regarding your child's health and immunization status.
Filling out the Arizona Religious Beliefs form can be straightforward, but many people make common mistakes that can lead to delays or issues with the exemption process. One frequent error is failing to place an “X” in the appropriate boxes next to the diseases for which they are requesting an exemption. This step is crucial, as it clearly indicates the specific vaccines the parent or guardian is opting out of. Without this, the form may be considered incomplete.
Another common mistake involves neglecting to provide initials and dates in the designated areas. Each section requires the parent or guardian to acknowledge that they have been informed of the risks associated with not vaccinating their child. Omitting initials or dates can result in the form being rejected or returned for correction, causing unnecessary delays.
Some individuals overlook the importance of signing the form. The parent or guardian’s signature is not just a formality; it is a declaration that they understand the implications of their decision. Without a signature, the form lacks validity and cannot be processed.
Additionally, many people fail to include their child's full name and date of birth. This information is essential for the child care facility to accurately identify the child and link the exemption to the correct individual. Incomplete identification details can lead to confusion and further complications.
It's also important to note that some parents do not read the instructions thoroughly. The form includes critical information about potential consequences, such as the possibility of exclusion from child care during outbreaks. Understanding these details can help parents make informed decisions and avoid future issues.
Another mistake is not keeping a copy of the completed form. After submission, having a copy can be beneficial for personal records and future reference. This practice ensures that parents can track their exemption request and address any follow-up questions that may arise.
Moreover, some individuals may not check the contact information for their local health department. It is advisable to ensure that the provided resources are accurate and accessible. This can help parents obtain further information about immunizations and potential health risks related to their decision.
Lastly, a lack of communication with the child care facility can lead to misunderstandings. Parents should confirm that the facility has received the exemption form and understands the implications of the request. Open dialogue can help prevent any surprises regarding their child's enrollment status.
The Arizona Religious Beliefs form is an important document for parents seeking to exempt their children from immunization requirements based on religious beliefs. This form is often accompanied by other documents that provide additional information or fulfill related requirements. Below is a list of forms and documents commonly used alongside the Arizona Religious Beliefs form.
Understanding these documents can help parents navigate the immunization exemption process in Arizona. Each form plays a role in ensuring that parents can make informed decisions while complying with state regulations regarding child care and education.
The Arizona Religious Beliefs form serves a specific purpose in documenting exemptions to immunization based on religious beliefs. Here are five documents that share similarities with this form:
When filling out the Arizona Religious Beliefs form, it’s essential to approach the task with care and attention. Here’s a list of six important do's and don'ts to consider.
By following these guidelines, you can ensure that your submission is complete and accurate, which will help facilitate the exemption process for your child.
Understanding the Arizona Religious Beliefs form can be crucial for parents navigating immunization requirements for their children. However, several misconceptions often arise regarding this form. Here are four common misunderstandings:
This is not true. The Arizona Religious Beliefs form specifically addresses exemptions based on religious beliefs. Personal or philosophical beliefs do not qualify for exemption under this form.
While the form provides an exemption for the specified vaccines, it does not permanently exempt your child from all vaccinations. Parents can rescind the exemption at any time and choose to vaccinate their child in the future.
In fact, this form is required for all preschools, child care facilities, and Head Start programs in Arizona. It applies universally, regardless of the specific institution your child attends.
It is important to understand that while the form allows for an exemption, children without vaccinations may be at increased risk during outbreaks of vaccine-preventable diseases. In such cases, they may be barred from attending child care until the outbreak risk has passed.
The Arizona Religious Beliefs form is mandatory for preschools and child care facilities to document a religious exemption to immunizations.
Parents must place an “X” next to the vaccines they wish to exempt their child from, and initial and date the corresponding boxes.
By signing the form, parents acknowledge that their child may be at increased risk for serious diseases without the vaccines.
Parents can rescind the exemption in the future if they decide to vaccinate their child.