COMMONWEALTH OF VIRGINIA
                        CERTIFICATE OF RELIGIOUS EXEMPTION


Name _________________________________Birth Date _______________________

Student I.D. Number __________________________________

The administration of immunizing agents conflicts with the above named
student's/my religious tenets or practices. I understand, that in the occurrence of an
outbreak, potential epidemic or epidemic of a vaccine-preventable disease in my/my
child's school, the State Health Commissioner may order my/my child's exclusion
from school, for my/my child's own protection, until the danger has passed.


________________________________________________________________________
Signature of parent/guardian/student 				Date



I hereby affirm that this affidavit was signed in my presence on



This _______________________________________Day of _____________________



Notary Public Seal










Form CRE-1; Rev. 00/92