Mississippi Process For Religious Exemptions From School Vaccination Requirements
Mississippi Process For Religious Exemptions From School Vaccination Requirements
Mississippi Process For Religious Exemptions From School Vaccination Requirements
Plaintiffs,
Defendants.
Defendant Dr. Daniel P. Edney, State Health Officer, submits this Notice of
Compliance with the Court’s preliminary injunction order, ECF No. 77, providing the
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INTRODUCTION
In April, this Court declared Mississippi’s School Vaccination Law, Miss. Code
The Court directed Dr. Edney, in his capacity as State Health Officer, and the
exemption process by July 15, 2023. The Court held that, if no process was provided
by the July 15 deadline, it would enjoin the law in its entirety, so that no vaccination
could be required for any K-12 students. See ECF No. 77 at 1-2, 37-39.
In compliance with the Court’s order, Dr. Edney and MSDH have developed a
religious exemption process, which is attached as Exhibit A. MSDH will publish that
process (and related forms) on its website on July 15, 2023 and begin accepting
religious exemption requests after that date. This notice provides the Court and all
parties with MSDH’s administrative guidance, instructions, and forms for the
the core components of many religious exemption laws around the country, and is
exemptions. The process is meant to respect the beliefs of parents who object to
vaccinating their children on religious grounds, while also protecting the health of
Mississippi’s 440,000 K-12 students and preserving the gains Mississippi has made
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BACKGROUND
Mississippi law requires that all children attending K-12 schools be vaccinated
against nine crippling and deadly diseases: chickenpox, measles, mumps, rubella,
diphtheria, pertussis, tetanus, polio, and Hepatitis B. See Miss. Code § 41-23-37 (the
“School Vaccination Law”); see also Miss. Dep’t of Health, Mississippi School
resources/2029.pdf. These diseases were once common in the United States, causing
thousands of hospitalizations and hundreds of deaths every year. See Centers for
https://www.cdc.gov/vaccines/vpd/index.html.
Shortly after the School Vaccination Law was enacted in 1978, a parent
challenged the law as unconstitutional because it did not allow religious exemptions.
The Mississippi Supreme Court rejected the challenge and held unanimously that
and compelling public interest . . . .” Brown v. Stone, 378 So. 2d 218, 222 (Miss. 1979).
Today, Mississippi’s school vaccination program is one of the most successful in the
country. 1 Over 99% of the K-12 student population has obtained the necessary
1Mississippi has the highest vaccine coverage of all states for the MMR, DTaP, polio, and
chickenpox vaccines. See Centers for Disease Control and Prevention, Morbidity and
Mortality Weekly Report, Vaccination Coverage with Selected Vaccines and Exemption Rates
Among Children in Kindergarten — United States, 2021–22 School Year (Jan. 13, 2023),
available at https://www.cdc.gov/mmwr/volumes/72/wr/pdfs/mm7202a2-H.pdf.
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vaccinating their children—challenge the School Vaccination Law on the theory that,
without a religious exemption process, it violates their First Amendment right to the
free exercise of religion. Plaintiffs sought an injunction to prohibit state and local
officials from enforcing the law unless the State were to provide a religious exemption
challenge, Attorney General Lynn Fitch agreed that a religious exemption was
Act, Miss. Code § 11-61-1 (“MRFRA”), which prohibits state laws from burdening
and noting that “the Attorney General admits in her briefs that not permitting an
option to request a religious exemption to the vaccination statute is not the least
restrictive means of further a compelling government interest,” ECF No. 77 at 15, the
Court issued a preliminary injunction against enforcement of the law, id. at 1-2, 37-
39. The Court did not adopt the Attorney General’s position that MRFRA provided a
religious exemption. Instead, the Court found that Plaintiffs were likely to succeed in
showing that the School Vaccination Law violates the First Amendment because it
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The Court’s preliminary injunction order provided that state and local officials
Mississippi Code § 41-23-37, unless they provide an option for requesting a religious
exemption from the law’s requirements.” ECF No. 77 at 2 (emphasis added). The
Court noted that MSDH has the duty under Mississippi law “[t]o formulate the policy
of the State Department of Health regarding public health matters within the
jurisdiction of the department” and “is responsible for assuring that all children in
No. 77 at 35. So the Court ordered Dr. Edney to “develop a process by which persons
may request a religious exemption from the [School Vaccination Law]” and to make
the process available on MSDH’s website by July 15, 2023. Id. at 1-2; 37-39.
In compliance with the Court’s order, Dr. Edney and MSDH have developed a
form-based religious exemption process for the School Vaccination Law, which aligns
with the State’s medical exemption process. As detailed in the Immunization Manual,
Exhibit A), the religious exemption process has several key components:
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See Exhibit A. These components are common features of religious exemption laws
around the country. See Centers for Disease Control and Prevention, Center for State,
Tribal, Local, and Territorial Support, State School Immunization Requirements and
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ARGUMENT
Dr. Edney and MSDH have developed a religious exemption process that
respects the beliefs of parents who have religious objections to vaccinating their
children, as required by the Court’s order, and also promotes Mississippi’s compelling
state interest in protecting its K-12 student population through vaccination against
crippling and deadly diseases. With this religious exemption process in place, Dr.
Edney believes Mississippi’s School Vaccination Law satisfies the strict scrutiny
To be clear, Dr. Edney does not endorse Plaintiffs’ views on vaccination or their
arguments that the School Vaccination Law is unconstitutional. Nor does Dr. Edney
agree with the Attorney General’s position that MRFRA provides a religious
exemption to the School Vaccination Law, though he respects her authority to opine
on questions of Mississippi law. 2 In Dr. Edney’s view, the School Vaccination Law is
exemption. As the Mississippi Supreme Court has held, the law serves the “overriding
and compelling public interest” of protecting school children against “crippling and
deadly diseases by immunization, and to the extent that [compelling public interest]
may conflict with the religious beliefs of a parent, however sincerely entertained, the
interests of the school children must prevail.” Brown, 378 So. 2d at 223.
2 See Miss. Code § 7-5-25 (authorizing Attorney General to issue written legal opinions);
Kennington-Saenger Theatres v. State ex rel. Dist. Atty., 18 So. 2d 483, 487 (Miss. 1944)
(“[T]he Attorney General, who is the responsible head of the legal department of the state,
shall have initial jurisdiction over those important legal questions which affect the general
interests or policy of the state.”).
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Dr. Edney respects this Court’s order, of course, and MSDH has worked
diligently to comply with it. By complying with the Court’s order, however, Dr. Edney
does not waive his, MSDH’s, or any other party’s right to request further relief from
The State of Mississippi, like all other states, has a compelling interest in
requiring that K-12 students be vaccinated against crippling and deadly childhood
diseases. The Mississippi Supreme Court recognized this “overriding and compelling
3 Just yesterday, the Fifth Circuit dismissed as moot plaintiffs’ First Amendment free-
exercise challenge to the Navy’s now-rescinded Covid-19 vaccine mandate. See U.S. Navy
Seals 1-26 v. Biden, 2023 WL 4362355 (5th Cir. July 6, 2023). Although the Court declined
to vacate its prior opinion denying a stay pending appeal, U.S Navy Seals 1-26 v. Biden, 27
F.4th 336 (5th Cir. 2022), that decision was not unanimous, see 2023 WL 4362355 at *7
(Graves, J., dissenting in part). That litigation will return to the district court, and
subsequent developments in the district court or on another appeal could impact the Court’s
analysis of the School Vaccination Law’s constitutionality. Two other circuits have recently
held that Covid-19 vaccine mandates—which allowed medical exemptions but not religious
ones—were generally applicable, subject to rational basis review, and did not violate the Free
Exercise Clause of the First Amendment. See We The Patriots USA, Inc. v. Hochul, 17 F.4th
266 (2d Cir.), opinion clarified, 17 F.4th 368 (2d Cir. 2021), and cert. denied sub nom. 142 S.
Ct. 2569 (2022); Does 1-6 v. Mills, 16 F.4th 20 (1st Cir. 2021), cert. denied sub nom., 142 S.
Ct. 1112 (2022).
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378 So. 2d at 222-23. The School Vaccination Law furthers that compelling interest
by protecting “the great body of school children attending the public schools in
Mississippi against the horrors of crippling and death resulting from poliomyelitis or
smallpox or from one of the other diseases against which means of immunization are
Other courts have recognized this compelling interest. “[A] state’s wish to
interest.” Workman v. Mingo Cnty. Bd. of Educ., 419 F. App’x 348 (4th Cir. 2011)
Whitlow v. California, 203 F. Supp. 3d 1079, 1089–90 (S.D. Cal. 2016); see also Does
1-6 v. Mills, 16 F.4th 20, 32 (1st Cir. 2021) (“Few interests are more compelling than
protecting public health against a deadly virus.”); Murray v. Cuomo, 460 F. Supp. 3d
430, 446 (S.D.N.Y. 2020) (“Controlling the spread of the disease in order to . . .
See Centers for Disease Control and Prevention, Center for State, Tribal, Local, and
4 In its preliminary injunction order, this Court did not disagree that Mississippi has a
compelling interest in requiring vaccinations to protect school children. Instead, applying
strict scrutiny, the Court considered only whether the School Vaccination Law—without a
religious exemption—was “narrowly tailored” or “the least restrictive means” of furthering
that compelling interest. ECF No. 77 at 23.
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efforts in the United States, and they “have made a major contribution to the
of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States, 298
the Mississippi Supreme Court in 1979, Mississippi’s school vaccination program has
become one of the most successful in the nation. For the last twenty years, Mississippi
“has been a national leader in immunization coverage, with over 99% of children who
enter kindergarten being protected.” See Miss. Dep’t of Health, Immunizations, What
“Mississippi children now have an excellent chance of growing up without the damage
that childhood diseases can cause, and are less likely to die from them than ever
before.” Id. According to the latest data published by the CDC, Mississippi had the
highest vaccine coverage of all states for the MMR, DTaP, polio, and chickenpox
vaccines in the 2021-2022 school year. See Centers for Disease Control and
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volumes/72/wr/pdfs/mm7202a2-H.pdf.
where vaccine coverage dips below target levels. In recent years, health authorities
have confirmed cases of measles and chickenpox—both of which are deadly for
children—and warned the public about the risk of outbreaks. 5 Maintaining high
vaccine coverage levels is important so that the population at large can maintain herd
immunity, which can prevent outbreaks of dangerous diseases. See Dina Nathanson,
Requirements and State Religious Freedom Restoration Acts, 42 Am. J. L. & Med. 621,
624 (2016). “When too many individuals are unvaccinated in a given population, . . .
the chance of encountering the targeted pathogen increases and one can no longer
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When the Mississippi Supreme Court decided Brown in 1979, the “horrors of
crippling and death resulting from poliomyelitis or smallpox or from one of the other
diseases against which means of immunization are known and have long been
practiced successfully,” 378 So. 2d at 222, were quite real and still recent. While those
horrors may seem like a distant memory today, that is only because Mississippi’s
preventing the return of those deadly diseases, which continue to infect and kill
implemented, the School Vaccination Law will satisfy strict scrutiny review under
the First Amendment. With the religious exemption, the law will no longer burden
any parent’s religious practices or beliefs, and it will be narrowly tailored to achieve
Mississippi’s compelling interest of protecting its K-12 population from crippling and
First, MSDH has designed the religious exemption process to match, as closely
as possible, the existing medical exemption process. All exemption requests, both
6 For the avoidance of doubt, Dr. Edney reiterates that he does not agree that the School
Vaccination Law is subject to strict scrutiny under the First Amendment or, even if it is, that
it could not satisfy strict scrutiny even without a religious exemption. See We The Patriots
USA, Inc., 17 F.4th at 280-290; Does 1-6, 16 F.4th at 29-35. Dr. Edney reserves, and does not
waive, his or MSDH’s right to request relief from or modification of the preliminary injunction
order if warranted by changes in law or circumstances.
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medical and religious, will be made to, reviewed, and granted by the State
a one-page form, after consultation with a physician or nurse about the benefits and
risks of immunization and being advised by that healthcare professional that their
child may be excluded from school if a vaccine-preventable disease (for which the child
Medical/Religious Exemption Form (Form 122) that can be used to enroll their child
verification, or any other form of “under oath” statements by a parent about his or
Third, the religious exemption does not permit state or local officials to inquire
into the sincerity of a parent’s religious beliefs. Instead, as set forth in Section 7.4 of
the Immunization Manual, the religious exemption will be granted so long as the
Alabama’s process, which Plaintiffs are familiar with and have identified as an
acceptable exemption process. See ECF No. 5 at 26-27 (Plaintiffs’ summary judgment
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exemption for her child must submit a written objection to a county health
department, receive education on the risks of not being immunized, and obtain a
of Public Health. See Ala. Code § 16-30-3(1); Ala. Admin. Code § 420-6-1-.02(4); Ala.
CONCLUSION
Dr. Edney and MSDH will publish the religious exemption process on MSDH’s
website on July 15, 2023, consistent with this Court’s preliminary injunction, and will
be prepared to accept and process exemption requests immediately after that date.
s/ Michael J. Bentley
Michael J. Bentley [MBN 102631]
Erin Saltaformaggio [MBN 103999]
mbentley@bradley.com
esaltaformaggio@bradley.com
BRADLEY ARANT BOULT
CUMMINGS, LLP
Suite 1000, One Jackson Place
188 East Capitol Street
Post Office Box 1789
Jackson, MS 39215-1789
Telephone: (601) 948-8000
Facsimile: (601) 948-3000
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CERTIFICATE OF SERVICE
I hereby certify that on July 7, 2023, I filed the foregoing using the Court’s ECF
s/Michael J. Bentley
Attorney for Dr. Daniel P. Edney,
State Health Officer
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The list of required immunizations is specified by the State Health Officer and is promulgated at
least annually as directed by state statute. All vaccines are to be given at the appropriate age and
intervals according to ACIP recommendations.
The MS Immunization Requirement and Schedules can be found on the MSDH website: at
https://msdh.ms.gov/msdhsite/_static/resources/2029.pdf
• Students are required to be age appropriately immunized with all required vaccines per
Mississippi School Immunization Law and Child Care requirements. All appropriate
immunizations must be documented on the Form 121 or Medical or Religious Exemptions as
documented on Form 122 and be presented upon admission.
For example: a child entering the 8th grade will be required to meet all kindergarten and
7th grade entry requirements.
The standard immunization schedule is available at all health department clinics and the catch- up
schedule for those children who are not current is available in the Epidemiology and Prevention of
Vaccine-Preventable Diseases - (“Pink Book”).
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General Instructions
To request a medical exemption from one or more required vaccinations, the MSDH Medical
Exemption Request (Form 139-M) must be completed and signed by the child’s physician
(pediatrician, family practitioner, or internist) who is duly licensed in Mississippi. Children
receiving specialized or tertiary care outside of the state may have medical exemption requests
completed and signed by their out of state tertiary or specialty care physician, as indicated
All medical exemption requests submitted by a child’s Mississippi licensed primary care physician
(pediatrician, family practitioner, in state tertiary care specialist or internist) that are fully
complete, including indication of the medical reason and designation of the exempted vaccines,
and signed by the child’s physician will be accepted by MSDH. Medical exemption requests
completed and signed by an out of state tertiary care physician will be reviewed individually.
All medical exemption requests are submitted to the MSDH Office of Immunizations by the provider,
reviewed for completeness, and signed by the State Epidemiologist or Deputy State Epidemiologist.
Once the medical exemption request is signed by the State Epidemiologist or Deputy State
Epidemiologist, a Certificate of Medical/Religious Exemption (Form 122) will be issued. Only the
Certificate of Medical/Religious Exemption (Form 122) signed and dated by the State
Epidemiologist or Deputy State Epidemiologist provides official, documented proof that a child has
been issued a medical exemption by MSDH. The original Certificate of Medical/Religious
Exemption (Form 122) will be housed at MSDH with a copy mailed to the parent and the
requesting physician.
Follow up and requests for additional information will be conducted by the State Epidemiologist or
Deputy State Epidemiologist for out-of-state medical exemption requests if needed. The parent and the
requesting physician will be contacted in the event that the out-of-state medical exemption request is
not accepted.
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Any requested medical exemption will be accepted if it meets the following criteria.
The MSDH Medical Exemption Request (Form 139-M) must be completed and signed by the
child’s physician (pediatrician, family practitioner, in state tertiary care specialist or internist) who
is duly licensed in Mississippi.
Medical exemption requests completed and signed by an out of state tertiary care physician will be
reviewed individually.
The same requesting physician (pediatrician, family practitioner, internist, or tertiary care
physician) must indicate on Form 139-M the medical condition of the child seeking exemption and
indicate the exemption status for each of the listed vaccines.
Form 139-M must be submitted to the Mississippi State Department of Health, Office of
Immunizations.
The State Epidemiologist or Deputy State Epidemiologist will review, accept, and sign the
completed medical exemption request and MSDH mail a copy of the Certificate of
Medical/Religious Exemption (Form 122) to the parent and the pediatrician, family practitioner,
internist, or tertiary care physician who submitted the Medical Exemption Request. The original
Certificate of Medical/ Religious Exemption (Form 122) will be housed at MSDH.
This policy will not amend the school law Section 41-23-37, Mississippi Code of 1972. Children
with a Certificate of Medical/Religious Exemption who are not adequately immunized will be
excluded from school if there is a threat of vaccine preventable diseases occurring in the community.
The child will be excluded until the infectious disease is no longer present or is no longer a threat to
the safety and welfare of the child or other children in the school.
Questions regarding the medical exemption process or the medical exemption request form should
be directed to the Office of Immunizations (601) 576-7751.
The medical exemption request form should be sent to the Mississippi State Department of Health
to the attention of the Office of Immunizations.
General Instructions
To request a religious exemption from one or more required vaccinations for Mississippi school entry,
the parent or guardian must complete the MSDH Religious Exemption Request (Form 139-R) and
submit to the County Health Department (appointment is required).
A review of all religious exemption requests for completeness will be conducted at the Mississippi State
Department of Health. Complete Religious exemption requests submitted per MSDH policy will be
accepted and signed by the State Epidemiologist or Deputy State Epidemiologist. Once the request is
reviewed and accepted, a Certificate of Medical/Religious Exemption (Form 122) will be issued. Only
the Certificate of Medical/Religious Exemption (Form 122) signed and dated by the State
Epidemiologist or Deputy State Epidemiologist provides official, documented proof that a child has
been issued a medical/religious exemption by MSDH. The original Certificate of Medical/Religious
Exemption (Form 122) will be housed at MSDH with a copy mailed to the parent and the daycare or
school indicated on the Religious Exemption Request Form.
Any requested religious exemption will be accepted by MSDH, and a Certificate of Medical/Religious
Exemption issued if following guidelines are met.
▪ The MSDH Religious Exemption Request (Form 139-R) must be completed signed and submitted to the
County Health Department (appointment is required) by the child’s parent or guardian.
▪ The parent/guardian will review the Vaccine Education video and will be given the opportunity to ask
questions.
▪ The Public Health Nurse will discuss the benefits and risks of immunizations with the parent/guardian.
▪ The Public Health Nurse will inform the parent/guardian that if any vaccine-preventable diseases for
which the child has not been adequately immunized are occurring in or threatening to occur in the
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community, the child will, for the safety and benefit of him/herself and other children, be excluded from
day care/school until the infectious disease is no longer present or is no longer a threat to the safety and
welfare of the child or other children in the day care/school.
▪ The form 139-R must be submitted by the County Health Department to the Mississippi State
Department of Health, Office of Immunizations through intraoffice mail.
▪ The State Epidemiologist or Deputy State Epidemiologist will accept and sign any Religious Exemption
request that includes all the required components. MSDH will mail a copy of the signed Certificate of
Medical/Religious Exemption (Form 122) to the parent and the daycare or school indicated on the
Religious Exemption Request. The original Certificate of Medical/Religious Exemption (Form 122) will
be housed at MSDH.
Data regarding medical/religious exemptions will be posted annually and will be maintained on the
MSDH website at Vaccine Exemptions - Mississippi State Department of Health (ms.gov) .
This policy will not amend the school law Section 41-23-37, Mississippi Code of 1972. Children with a
Certificate of Medical/Religious Exemption who are not adequately immunized will be excluded from
school if there is a threat of vaccine preventable diseases occurring in the community. The child will be
excluded until the infectious disease is no longer present or is no longer a threat to the safety and
welfare of the child or other children in the school.
Questions regarding the religious exemption process or the religious exemption request form should be
directed to the Office of Immunizations at (601) 576-7751.
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Date of Request: _______________ Name of School/Child Care Facility: ___________________ City/County: ______________
Address:
Street City State Zip
Indicate the exemption status for each vaccine in the table below (an exemption status is required for each vaccine):
Indicate the exemption status for each vaccine by checking the correct box in the table
below (an exemption status is required for each vaccine):
Vaccine Permanent Temporary No Vaccine Permanent Temporary No
(Include Exemption (Include Exemption
Date) Date)
DTaP MMR
Hepatitis B Pneumococcal
Hib* Tdap**
IPV Varicella
*For childcare only **For 7th grade entry
Indicate reason for medical exemption (use additional sheets if needed)
Print name of child’s pediatrician, family physician, or internist licensed in Mississippi (or out-of-state tertiary care physician)
Address
Street City State Zip
I declare that:
• In my medical opinion, the named individual has a medical reason for exemption from the above vaccines and that the physical condition of
this child to be such that the vaccination(s) specified on this form would endanger their life or health and outweighs the risk of death or
disability from the vaccine preventable disease.
• I have discussed the benefits and risks of immunizations with the parent/guardian as a condition for exemption.
• I have informed the parent/guardian that if any vaccine-preventable diseases for which the child has not been adequately immunized are
occurring in or threatening to occur in the community, the child will, for the safety and benefit of him/herself and other children, be excluded
from day care/school until the infectious disease is no longer present or is no longer a threat to the safety and welfare of the child or other
children in the day care/school.
Signature of child’s pediatrician/family physician/internist licensed in Mississippi:
(Or out-of-state tertiary care physician)
INSTRUCTIONS
• The child’s parent or guardian must complete and sign the Religious Exemption Request Form indicating the vaccines for which the child
will be exempted.
• Submit the completed form to the County Health Department (appointment is required). For information regarding County Health
Department hours of operation go to www.msdh.ms.gov and to schedule an appointment call 855-767-0170.
• Additional steps will be completed at the County Health Department. For more about the process visit www.msdh.ms.gov .
• The completed Religious Exemption Request is submitted to the State Epidemiologist or Deputy State Epidemiologist for signature, and a
copy is sent by mail to the school and the parent/guardian at the addresses indicated below.
Date of Request __________ Name of School/Child Care Facility: ____________________ City and County: ______________
Address: _________________________________________________________________________________________________
Street City State Zip
Indicate the exemption status for each vaccine by checking the correct box in the table
below (an exemption status is required for each vaccine):
Vaccine Permanent No Exemption Vaccine Permanent No Exemption
DTaP MMR
Hepatitis B Pneumococcal
Hib* Tdap**
IPV Varicella
*For childcare only. **For 7th grade entry only.
I, ____________________, am requesting a religious exemption from the above vaccines for my child, _________________________.
• I understand that not vaccinating my child with the vaccination(s) specified above can endanger their life or health, and the life or
health of other children; and that the religious reasons for not vaccinating my child outweigh the risk of death or disability to my
child or other children from the vaccine preventable disease.
• I understand that if any vaccine-preventable diseases for which my child has not been adequately immunized are occurring in or
threatening to occur in the community, my child will, for the safety and benefit of him/herself and other children, be excluded from
day care/school until the infectious disease is no longer present or is no longer a threat to the safety and welfare of my child or other
children in the day care/school.
Verification of Process:
• Religious Exemption Request completed and signed by parent/guardian.
• Parent/guardian has viewed Vaccine Education video and has been given the chance to ask questions.
• I have discussed the benefits and risks of immunizations with the parent/guardian as a condition for exemption.
• I have informed the parent/guardian that if any vaccine-preventable diseases for which the child has not been adequately immunized are
occurring in or threatening to occur in the community, the child will, for the safety and benefit of him/herself and other children, be excluded
from day care/school until the infectious disease is no longer present or is no longer a threat to the safety and welfare of the child or other
children in the day care/school.
Signature of Health Department Nurse____________________________________ Date:
Printed Name of Health Department Nurse________________________________
County of Health Department: __________________________________________ Phone: _________________
This document should be submitted through intraoffice mail to: Office of Immunizations MSDH Central Office in Jackson, Mississippi
Medical Exemption – A medical exemption from the required vaccinations for the above-named individual is
hereby issued on the basis of a specific medical condition initiated by the child’s pediatrician, family physician, or
internist.
Religious Exemption - A religious exemption from the required vaccinations for the above-named individual is
hereby issued on the basis of religious reasons requested by the guardian/parent.
Vaccines Exempted
DTaP DT-Ped Tdap Td-Adult IPV Measles
Permanently
Temporarily Until: Date
Address:
______________________________________________________________________________________________
Street City State Zip
Signature Date
School Officials: Do Not File this form in cumulative folder. The form must be maintained in a separate file and
reviewed periodically to ensure validity
This form may be used for Day Care or K -12 Exemptions.