INSTRUCTIONS FOR COMPLETING

ILLINOIS CERTIFICATE OF RELIGIOUS EXEMPTION

TO REQUIRED IMMUNIZATIONS AND/OR EXAMINATIONS FORM

Who may use the Certificate of Religious Exemption to Required Immunizations and/or Examinations Form:

• Parents or legal guardians who are requesting a religious exemption to immunizations or examinations must use

this form for students entering kindergarten, sixth, or ninth grades.

• A separate form must be used for each child with a religious exemption enrolled to enter any public, charter,

private or parochial preschool, kindergarten, elementary or secondary school.

• This form may not be used for exemptions from immunizations and/or examination for personal or philosophical

reasons. Illinois law does not allow for such exemptions. (See excerpts below from Public Act 099-0249 enacted

August 3, 2015 at page bottom.)

When use of this form becomes required : October 16, 2015

How to complete the Certificate of Religious Exemption to Required Immunizations and/or Examinations Form :

• Complete the Parent/Guardian sections, which include key information about the student and the school the

student will be entering, and the immunizations or examinations for which religious exemption is being requested.

Provide a statement of religious belief(s) for each vaccination/examination requested .

• The form must be signed by the child’s parent or legal guardian AND the child’s health care provider*

  responsible

for performing the child’s health examination .

• Submit the completed form to local school authority on or before October 15th of the school year, or by an earlier

enrollment date established by a school district.