Texas Department of State Health Services
Vaccines build your child's health

Affidavit Request for Exemption from Immunizations for Reasons of Conscience


* 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
 
*Address to which Affidavit Forms should be mailed (This should be your permanent mailing address.)
 
Apartment/Unit/Suite Number
*City   *State   *Zipcode      
Phone

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
     
*1
 
 2
 
 3
 
 4
 
 5
 
 6
 
 7
 
 8