The Arizona Religious Beliefs form is an official document required by Arizona law for preschools and child care facilities. This form allows parents to request an exemption from immunization based on their religious beliefs. While the Arizona Department of Health Services (ADHS) advocates for immunization as a critical health measure, it also acknowledges the rights of parents to make decisions aligned with their religious teachings.
The Arizona Religious Beliefs form is a crucial document for parents and guardians seeking an exemption from immunization requirements for their children enrolled in preschools, child care facilities, and Head Start programs. This official form, mandated by Arizona law, allows families to formally declare their religious beliefs that oppose vaccination. The Arizona Department of Health Services (ADHS) emphasizes the importance of immunization as a key public health measure while also respecting the rights of parents to make decisions based on their religious convictions. To complete the form, parents must indicate their choice to exempt their child from specific vaccines by marking the corresponding boxes for diseases such as diphtheria, tetanus, and measles, among others. Each entry requires initials and the date, acknowledging the potential health risks associated with not vaccinating. The form also includes a section that informs parents about the serious consequences of vaccine-preventable diseases, reinforcing the need for informed decision-making. Additionally, it outlines the possibility of rescinding the exemption in the future and provides resources for further information on vaccinations and local health services. Understanding this form is essential for parents navigating the intersection of health care and personal beliefs in Arizona.
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)
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