Exemption Form

Barbara Neilly                                                                                                                                                                                                   Michael Marin -Zboray 

 Principal                                                                                                                                                                                                                                                                     Assistant Principal    


Conners Emerson School

11 Eagle Lake Road

Bar Harbor, Maine, 04609


(207) 288-3631      fax:(207) 288-4706


As a parent/guardian of _______________________________________ (Student name)

in grade _______________ and date of birth _______________________.

 I am requesting a waiver for the following immunizations: All required immunizations: ______ Specific immunizations: DTAP_____ I/OPV ______ MMR_____Varicella _____

I understand that in the case of an outbreak of the specific disease for which my child is not protected, my child will be kept out of school and school activities. The length of time my child will be kept out of school may vary from a week to over a month depending on the disease and length of the outbreak. I also understand that if my child is kept out of school, the school is not required to provide off-site classes or tutoring. The school may make reasonable accommodations to assist my child in keeping up with classwork.

I am requesting a waiver for:

Sincere Religious Belief _______ 

Philosophical Reason _______

My explanation is as follows: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Signed by: ______________________________________________ 

Relationship to student: _________________________