CO Request

* Required fields

First name, last name, and birth date are required for each individual; the middle name is optional.
If exemptions are requested for only one individual, the information must be entered on the first line.
Valid birth dates are required; future birth dates are not allowed.

I wish to obtain an Exemption from Immunizations for Reasons of Conscience Affidavit Form. Please provide me with exemption affidavit forms for the individuals listed below (maximum 5 forms per individual).

Name of Parent, Legal Guardian, or Self
* First Name first name req.
* Last Name last name req.

* Address to which Affidavit Forms should be mailed (This should be your permanent U.S. mailing address.)
req.

Apartment/Unit/Suite Number

* City city req.
* State * Zipcode zip req.

* Phone (valid phone numbers in these formats are accepted: (234) 567-8989, (234) 567.8989, 2345678989, 234-567-8989, 234.567.8989)
ph. req. Please enter a valid phone number using an acceptable format.

Please type the information below EXACTLY as you would like it to appear on the affidavit.

First Name

Middle Name

Last Name

Birth Date (mm/dd/yyyy)

Number of Forms

first name req. last name req. DOB req.

* 1

Not a valid date!

Affidavit Request for Exemption from Immunizations for Reasons of Conscience