Example of Vaccine/Immunization Waiver, which may be submitted to any daycare,
school or children's facility in the state of California
(Date)
Parent's Name & Address
To Whom It May Concern,
We, the parents of ____________________ , hereby claim exemption from the immunization requirement for
Philosophical/Personal reasons, citing California Health & Safety Code 120365 in accordance with Title 17,
CCR Section 6051 (2003).
________________________________________ _____________
Mother's Signature Date
________________________________________ _____________
Father's Signature Date