Certificate of Exemption Form Instructions

Who may

use the Exemption from Immunization Form:

• Students

requesting a religious or medical exemption to immunization may use this form.

(Must be either 0-18 years of age OR a student between daycare to 12th grade)

• This

form may be used for all children with an exemption going into any public, private or parochial preschool,

kindergarten, elementary, secondary school, or home school and for children attending daycare or childcare

facilities.

• This form may not be used for exemption from immunization for personal or philosophical r

easons. New Mexico

law does

ot allow for such

exemption. (Please see New Mexico Law 24-5-3 at

page bottom.)

How to Complete the Exemption from Immunization Form:

• Form must be completed and submitted by the parent or guardian on behalf of the child

• Fill out all blank lines and check boxes, including the check boxes for the religious or medical options.

• For medical exemptions, attach the letter from your licensed physician, a physician assistant, or a certified

nurse practitioner to this form.

• For religious exemptions using an affidavit, please attach the affidavit to this form.

• For religious exemptions using a written affirmation, please use the space provided on the form

• The form must be signed and dated by the parent/guardian in front of a notary public, and must also be

signed and dated by the notary public on the same date.

• The parent/guardian must provide a copy of the notarized form to the school nurse and/or administrator.

• Mail the form to the New Mexico Department of Health at 1190 St. Francis Drive, Suite-1250/PO Box 26110,

Santa Fe, NM 87502-6110. You may also submit your form in a drop box at the Department of Health in Santa

Fe, NM (Harold Runnels Building).

Depar

tment of Health Exemption from Immunization Form Processing:

• The Department of Health has 60 days from receipt of the Certificate of Exemption Form to either approve or

not

approve the request (see NMAC 7.5.3 below). Make sure that the Department of Health receives t

he form

at least 60 days prior to the day your child starts school.

• Upon approval, the Department of Health will mail you one copy of the approved form. The Parent/Guardian

must take one copy of

the approved form to your child’s pre-school, school, daycare, or childcare facility.

• If your request is not approved, you will get a letter from the Department of Health with the reasoning for the

disapproval. You may then resubmit your request with the necessary changes.

New Mexico Immunization Exemption Law (24-5-3):

Any minor child through his parent or guardian may file with the health authority charged with the duty of enforcing the

immunization laws:

(1)

A certificate from a licensed physician, a physician assistant, or a certified nurse practitioner stating that the

physical

condition of the child is such that immunization would seriously endanger the life or health of the child; or

(2)

Affidavits or written affirmation from an officer of a recognized religious denomination that such child’s parents or

guardians are bona fide members of a denomination whose religious teaching requires reliance upon prayer or

spiritual means alone for healing;

(3)

Affidavits or written affirmation from his parent or legal guardian that his religious beliefs, held either individually or

jointly with others, do not permit the administration of vaccine or other immunizing agent.

NMAC 7.5.3: “Within sixty (60) days of receipt of a request for exemption from immunization, the director of the public health

division or the designee shall review the request to determine whether the certificate has been duly completed."

For any questions on how to complete the form, please contact, (833) 882-6454

DOH Use Only:

DISAPPROVED

BEGINS ON

Date

CERTIFICATE OF EXEMPTION

FROM SCHOOL/DAYCARE IMMUNIZATION REQUIREMENTS

Please Print Clearly, Complete All Fields, Use CAPITAL LETTERS ONLY - Must be Legible!

Parent/Guardian Information

Child Name

School Name

Child and School Information

Mailing

Address

State

Phone

Gender

Race

Diphtheria

Pertussis

Pneumococcal

Directions

Measles

Mumps

Hepatitis A

Hepatitis B

Varicella (Chicken Pox)

Meningococcal

I request that the one year (12 month) period

this e

xemption form is valid begins on:

m m d d y y y y

Please complete this form.

Check the box that corresponds to your request for exemption and include the required information. Then in the presence of a

Notary Public, please sign and date this certificate and have it notarized. IT IS THE PARENT/GUARDIAN’S RESPONSIBILITY TO ENSURE AN

APPROVED COPY OF THIS EXEMPTION CERTIFICATE IS FILED WITH THE CHILD’S SCHOOL.

I request exemption from immunization requirements in accordance with:

NMAC 7.5.3.8 A.1, and I am attaching an affidavit or certificate from a licensed physician, physician assistant, or certified nurse practitioner

attesting that any of the required immunizations would seriously endanger the life or health of my child.

NMAC 7.5.3.8 A.2, and I am attaching an affidavit or written affirmation from an officer of my denomination stating we are bona fide members of a

recognized religious denomination which requires reliance on prayer or spiritual means alone for healing.

NMAC 7.5.3.8 A.3, and I hereby certify through the written affirmation below, or attached affidavit, that my religious beliefs, held either

individually or jointly with others, do not permit the administration of vaccine or other immunizing agents.

I UNDERSTAND THIS REQUEST IS SUBJECT TO THE APPROVAL OF THE NEW MEXICO DEPARTMENT OF HEALTH. I HAVE READ THE ‘COMPULSORY

IMMUNIZATION REGULATIONS’ AND UNDERSTAND THE RISK OF NON-IMMUNIZATION FOR MY CHILD. I UNDERSTAND THAT THIS CERTIFICATE,

IF APPROVED, IS VALID FOR A PERIOD NOT TO EXCEED TWELVE MONTHS AND WILL EXPIRE THEREAFTER. IF I WISH TO REQUEST ANOTHER

EXEMPTION AFTER THE TWELVE MONTH PERIOD, I MUST COMPLETE ANOTHER CERTIFICATE OF EXEMPTION AND SEEK APPROVAL.

I ALSO UNDERSTAND THAT WHERE ANY CASE OF COMMUNICABLE DISEASE OCCURS OR IS LIKELY TO OCCUR IN MY CHILD’S SCHOOL, THE

DEPARTMENT OF HEALTH MAY REQUIRE THE EXCLUSION OF INFECTED PERSONS AND NON-IMMUNIZED PERSONS (7.4.3.9 NMAC - Rp, 7 NMAC

4.3.9, 8/15/2003).

I swear that all the foregoing statements are true to the best of my information, knowledge and belief. Notary Seal

Parent/guardian’s name (print clearly)

Parent/guardian’s signature: Date:

NOTARY

Subscribed and sworn before me this day of , 20 .

My Commission expires:

Notary’s Signature

Revised 2023

Authorized Signature

EXPIRES ON

Date

Native American

Asian

Black

White

Other

Male Female

Hispanic Non-Hispanic

I object to my child receiving the following:

Zip Code

School District

School Address

Zip

Child’s

m m d d

y y y y

Grade

Ethnicity

(As specified on

birth certificate)

APPROVED

m m d d y y y y

Hib - Haemophilus Influenza type B

Rubella

Polio

Full Name

Child Date of Birth

City

School Address

School City

State

Mail Original Form to:

NM Immunization Program

1190 St. Francis Drive, Suite-1250

PO Box 26110

Santa Fe, NM 87502-6110

ALL REQUIRED VACCINES

Tetanus