Immunization Exemption Form In accordance with the Ohio Revised Code – Amended Section 3313.671 (Part A), I hereby request thatName of Student(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Be exempt from school immunizations. I understand that due to the lack of immunizations, should any epidemic or communicable disease outbreak occur, the above named student may be excluded from attendance at all school functions in which other students are present.Signature of Parent(Required)