Texas Department of State Health Services
Vaccines build your child's health

Affidavit Request for Exemption from Immunizations for Reasons of Conscience

* Required fields

First name, last name, and birth date are required for each individual; the middle name is optional.
If exemptions are requested for only one individual, the information must be entered on the first line.
Valid birth dates are required; future birth dates are not allowed.

I wish to obtain an Exemption from Immunizations for Reasons of Conscience Affidavit Form. Please provide me with exemption affidavit forms for the individuals listed below (maximum 5 forms per individual).

Name of Parent, Legal Guardian, or Self
*First Name   
*Last Name   
*Address to which Affidavit Forms should be mailed (This should be your permanent mailing address.)
Apartment/Unit/Suite Number
*State   *Zipcode  
*Phone (valid phone numbers in these formats are accepted: (234) 567-8989, (234) 567.8989, 2345678989, 234-567-8989, 234.567.8989)

Please type the information below EXACTLY as you would like it to appear on the affidavit.

First Name
Middle Name
Last Name
Birth Date (mm/dd/yyyy)
Number of Forms