missouri department of health and senior services
RELIGIOUS IMMUNIZATION EXEMPTION
required under the missouri state immunization law (section 167.181, rsmo) of children attending public, private, and
parochial or parish schools.
we strongly encourage you to immunize your child, but ultimately the decision is yours. please discuss any concerns you have with a trusted
healthcare provider or call the immunization coordinator at your local or state health department. your final decision affects not only the health
of your child, but also the rest of your family, the health of your child’s friends and their families, classmates, neighbors, and community.
unimmunized children have a greater risk of contracting and spreading vaccine-preventable diseases to babies who are too young to be fully
immunized and those who cannot be immunized due to medical conditions. in the event of an outbreak of a vaccine-preventable disease
within a particular facility, children who are not fully immunized or do not have documented laboratory evidence of immunity shall not be
allowed to attend school or day care until the local health authority declares the designated outbreak or health emergency has ended.
name of child (print or type)
THIS IS TO
CERTIFY THAT Rayshaun Jackson
should be exempted from receiving the following checked immunization(s) because immunizations violate
my religious beliefs:
diphtheria hepatitis b mmr pertussis polio
tetanus varicella other __________________________________________________________
parent/guardian name (print or type) parent/guardian signature date
Diya Love 10/16/2025
mo 580-1723 (4-12) imm.p.11a
missouri department of health and senior services
RELIGIOUS IMMUNIZATION EXEMPTION
required under the missouri state immunization law (section 167.181, rsmo) of children attending public, private, and
parochial or parish schools.
we strongly encourage you to immunize your child, but ultimately the decision is yours. please discuss any concerns you have with a trusted
healthcare provider or call the immunization coordinator at your local or state health department. your final decision affects not only the health
of your child, but also the rest of your family, the health of your child’s friends and their families, classmates, neighbors, and community.
unimmunized children have a greater risk of contracting and spreading vaccine-preventable diseases to babies who are too young to be fully
immunized and those who cannot be immunized due to medical conditions. in the event of an outbreak of a vaccine-preventable disease
within a particular facility, children who are not fully immunized or do not have documented laboratory evidence of immunity shall not be
allowed to attend school or day care until the local health authority declares the designated outbreak or health emergency has ended.
name of child (print or type)
THIS IS TO
CERTIFY THAT
should be exempted from receiving the following checked immunization(s) because immunizations violate
my religious beliefs:
diphtheria hepatitis b mmr pertussis polio
tetanus varicella other __________________________________________________________
parent/guardian name (print or type) parent/guardian signature date
mo 580-1723 (4-12) imm.p.11a
