Session(s) attending _ _ _

Please fill out completely, SIGN and return to Camp 2 weeks prior to your campers session

Camper’s Name

CAMP WINNARAINBOW Immunization Exemption Form To be completed when a parent, guardian, responsible adult is claiming exemption from immunizations for a Camper.

Exemption being claimed:

Medical Exemption

Personal Beliefs Exemption

Licensed Helath Care Professional

September - May: 1301 Henry Street, Berkeley, CA 94709 • June - August: PO Box 1359, Laytonville, CA 95454 Phone: 510/525-4304 fax: 510/528-8775 • Phone: 707/984-6507 fax: 707/984-8087

Year-round email: arainbow@mcn.org • Internet: www.campwinnarainbow.org

I, as a licensed health care professional, feel the following vaccines are not indicated for the above named camper because of the listed medical reasons.Contraindicated vaccines:_________________________________________________________________________________________________________________________________________________________________________________Medical reasons:________________________________________________________________________________________________________________________________________________________________________________________

Signature of Licensed Health Care Professional: ________ __________________Date: _______________

Office Address__________________________________________________________Office Phone _________________ Number Street Suite City State Zip

I, as the parent or guardian or adult who has assumed responsibility care and custody of the above named camper am filing this document with Camp Winnarainbow idicating which immunizations required by CA law have been given and which immunizations have not been given on the basis that they are contrary to our family’s beliefs.Vaccinations given (please provide immunization records):_____________________________________________________________________________________________________________________________________________________Vaccinations not given due to personal beliefs:_______________________________________________________________________________________________________________________________________________________________Check one of the boxes below:

D Receipt of information: I have received information provided by an licensed health care practitioner regarding 1) the benefits and risks of immunization and 2) the health risks to me and to the community.D Religious beliefs: I am a member of a religiona which prohibits me from seeking medical advice or treatment from authorized health care practitioners. (Signature of a health care practitioner not required below)

Signature ofparent, guardian, responsible adult________________________________________Date: _______________

Provision of information: I have provided the parent or guardian of the camper named above, the adult who has assumed responsibility for the care and custody of the camper with information regarding 1) the benefits and risks of immunization and 2) the health risks to the camper and to the community of thecommunicable diseases for which immunization is require in California.

Signature of Licensed Health Care Professional: ________ ____ Date:___________________

Office Address__________________________________________________________Office Phone _________________ Number Street Suite City State Zip