Date

School or Governing Authority

Address
City, State, Zip Code

RE: Vaccination Exemption

Dear (Name):

I am writing to request an exemption from (institution name)‘s immunization

requirements based upon my philosophical objections to the practice of immunization. I
am claiming this in accordance with California Health and Safety Code Section 120365,
which reads as follows:

Immunization of a person shall not be required for admission to a school

or other institution listed in Section 120335 if the parent or guardian or
adult who has assumed responsibility for his or her care and custody in the
case of a minor, or the person seeking admission if an emancipated minor,
files with the governing authority a letter or affidavit stating that the
immunization is contrary to his or her beliefs.

This letter serves as my formal request to (institution name) that I be exempt from the
required immunizations because this medical practice is contrary to my beliefs. Thank
you for your attention to this important matter. If you have any questions do not hesitate
to contact me.

Sincerely,

Your Name

Enclosure: (YOUR STATE) Health and Safety Code

Xc: Michael Peabody, Esq., Vice President

Seventh-day Adventist Church State Council