STATE OF TENNESSEE

DEPARTMENT OF EDUCATION
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PHIL BREDESEN 6 FLOOR, ANDREW JOHNSON TOWER LANA C. SEIVERS, Ed.D.
GOVERNOR 710 JAMES ROBERTSON PARKWAY COMMISSIONER
NASHVILLE, TN 37243-0375

Model Form
Religious Exemption from Vaccination(s)

Child’s Name________________________________________________________________

Parent/Legal Guardian Name___________________________________________________

Address _________________________________________

State ______ Zip ______________

Phone (_____)____________________

Pursuant to Tennessee Code Annotated §49-6-5001(b)(2), I am declining

vaccination(s) for my child because the vaccination(s) conflict with my
religious tenets and practices.

I declare under penalty of perjury that the foregoing is true and correct.

Parent/Legal Guardian Signature __________________________

Date __________________

ED-5379