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VACCINATION EXEMPTION PURSUANT TOREVISED CODE OF WASHINGTON: RCW 28A.210.090
RCW 28A.210.090 Immunization program – Exemptions from on presentation of alternativecertifications.
Any child shall be exempt in whole or in part from the immunization measures required by RCW 28A.210.060 through28A.210.170 upon the presentation of any one or more of the following, on a form prescribed by thedepartment of health:1) A written certification signed by any physician licensed to practice medicine pursuant to chapter 18.71 or 18.57RCW that a particular vaccine required by rule of the state board of health is, in his or her judgment, not advisable for the child: PROVIDED, That when it is determined that this particular vaccine is no longer contraindicated, the childwill be required to have the vaccine;2) A written certification signed by any parent or legal guardian of the child or any adult in loco parentis to the childthat the religious beliefs of the signator are contrary to the required immunization measures; and3) A written certification signed by any parent or legal guardian of the child or any adult in loco parentis to the childthat the signator has either a philosophical or personal objection to the immunization of the child.RCW 28A.210.090(3) does not require you to disclose what your philosophical or personal objection to immunizationis. As with any medical decision, the decision to vaccinate or not is a right of the individual or parent. The State of Washington, your doctor and public health employees cannot force you or your child to be vaccinated. Your childcannot be excluded from a school or public program because you have exercised your right to not vaccinate.
VACCINATION EXEMPTION FORM
I,____________________________, as the parent, guardian or person in
(insert your name)
loco parentis of the child __________________________ after considering the
(insert child’s name)
risks and benefits of the vaccine(s) do hereby decide not to vaccinate my childwith the following vaccines:
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Diphtheria
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Measles
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Other 
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Tetanus
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Mumps
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Pertussis
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Rubella
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Polio
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Haemophilus influenzae type b
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Hepatitis B
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Varicella
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Smallpox
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Anthrax
This is pursuant to my right to refuse vaccination on the statutory grounds of “personal objection”. Pursuantto the statute I am providing a copy of the statement to the child’s school administrator or operator of thegroup program pursuant to RCW 28A.210.090.Date: ____________________ __________________________________ Parent/Guardian or Person in loco parentis
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