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Immunization Indemnification Certificate

We, the undersigned parents or guardians or adult student, request that the below named person be 
exempted from compulsory immunization of health and safety reasons until this Indemnification 
Certificate has been duly executed in accordance with all the stated conditions.

Student’s Name ______________________________________________

Conditions

The school district or school board shall select a fully accredited physician to administer the shots who is 
agreeable to the parents of the adult student.
Prior to administering the shots, the physician shall submit to the parents or guardians or adult student a 
sample of the vaccine to be administered for analysis by a biochemist of their choice to be certain that it 
contains no elements harmful to health.
The State Officers and the Local School Board shall, by affixing their signatures to this document, agree 
to indemnify the recipient of the immunization for any illness, injury, and damages attributable to the 
shots administered; and in the case of death or disability of the recipient attributable to the shots 
administered, the undersigned State officers and Local School Board shall indemnify the executor or 
administrator of the deceased or disabled recipient for all damages arising from such death or disability.
In the event of any dispute over indemnification, the state officers and the local school board agree to pay 
all attorneys’ fees and court costs required by the recipient or his or her estate to collect the 
indemnification.

For the State of ___________________________________________________

(Signature) _______________________________________State Superintendent of Public Instruction

(Signature) _______________________________________State Commissioner of Public Health


For the Local School Board of ______________________________________________

(Signature) _________________________________________Superintendent of Schools

(Signature) _________________________________________President of School Board

Upon receipt of this properly executed certificate, we, the undersigned parents or guardians, will deliver 
our minor child for the required immunization shots. In doing so, neither we nor the minor child waive 
any right to damages for malpractice from the physician or to file a claim with the National Vaccine 
Injury Compensation Program.

Parents’ or Guardian Signatures _______________________________________________

For an adult student: I will, upon receipt of this properly executed certificate, submit myself to the 
required immunization shots. In so doing, I do not waive any right to damages for malpractice from the 
physician or to file a claim with the National Vaccine Injury Compensation Program.

Adult Student’s Signature ________________________________________________

Address _______________________________________________________

City _______________________________ State ______________________ Zip ________________

Request for Hearing

In the event that this document is not duly executed by the School District and the Local School Board, 
we, the parents, guardian, or adult student, request an individual hearing before the School Board, prior to 
any attempt to remove the above named student from school, where the questions of health, safety, 
welfare, civil rights, discrimination, invasion of privacy, assault and battery, and equal treatment under 
the law can be raised.