Personal Details

First Name:  
Middle Name:  
Last Name:  
Date of Birth (mm/dd/yy):

Vaccine Required for School Entry
Check Vaccine Declined

Statement of Exemption

I am declining the Booster dose of the vaccine above due to a religious belief whose teachings are opposed to immunization, a personal belief that is opposed to immunization with the COVID-19 booster shot or a medical reason that is deemed unsafe for me to have the COVID-19 booster shot. I understand that I still have to have received a full vaccine series (2 shots of Moderna or Pfizer, 1 shot of Johnson & Johnson) in order to participate in any activity at the Joffrey Ballet School. The information I have provided on this form is complete and accurate, and I acknowledge and understand the following:

• I may change my mind at any time and accept vaccination(s) for my myself/child in the future.
• Those who are not vaccinated have a significantly increased likelihood of becoming infected and/or ill after exposure to COVID-19. Close contacts who are unvaccinated have different isolation rules, according to CDC policy.