JLCB-E4 - Immunization Exemption Form IEP
JLCB-E4 - Immunization Exemption Form IEP
Student Name: _______________________________ Date of Birth: ____________________
In accordance with MRS 20-A §6355, a student covered by an Individualized Education Plan on September 1, 2021 who elected a philosophical or religious exemption from immunization requirements on or before September 1, 2021 pursuant to the law in effect prior to that date may continue to attend school under that student's existing exemption as long as:
A. The parent or guardian of the student provides a statement from a licensed physician, nurse practitioner or physician assistant that the physician, nurse practitioner or physician assistant has consulted with that parent or guardian and has made that parent or guardian aware of the risks and benefits associated with the choice to immunize; or
B. If the student is 18 years of age or older, the student provides a statement from a licensed physician, nurse practitioner or physician assistant that the physician, nurse practitioner or physician assistant has consulted with that student and has made that student aware of the risks and benefits associated with the choice to immunize.
I/we have elected to have a philosophical or religious exemption from immunization requirements for this person prior to Sept 1, 2021 and are continuing to do so as this person has an individualized education program (IEP) in place.
This exemption is for the following immunizations:
o All required immunizations, please reference JLCB-R Maine School Immunization Requirements.
o The following specific immunizations:
o Diphtheria, Tetanus, Pertussis
o Polio
o Measles/Mumps/Rubella
o Varicella
o Meningococcal disease
I understand that I must provide a statement from a healthcare provider as listed above to accompany this form and must do this annually. The Special Education Director of this person’s school district will certify that an IEP is currently in place on or before September 1, 2021.
I understand that in the case of an outbreak of a specific disease, for which my child is not protected, my child may be kept out of school and school activities as advised by the Maine Centers for Disease Control and Prevention. The length of time my child will be kept out may vary depending on the disease and the 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 child’s educational needs may be met by making arrangements for the delivery of school assignments, correction of papers, and similar activities which can be accomplished at home. Any child who is unable to take examinations during this period shall be afforded the opportunity to make up the examinations, similar to arrangements made for children who have other excused absences.
__________________________________________________________________________________________________
Printed Name and Signature Relationship to student Date
---------------FOR SCHOOL USE ONLY---------------
⧠ Statement from healthcare provider received.
⧠ I, _____________________________, a school administrative unit representative for Special Education, certify that an IEP is in place for the student listed above on or before September 1, 2021 which makes them eligible to maintain the philosophical or religious exemption for immunization requirements.
_____________________________________________
Signature Date
Maine Department of Education Template Updated 3/2021
Cross Reference: JLCB and JLCB-R
Policy Adopted: March 16, 2022