Dancer Details

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

Program

Parent/Guardian Details

Parent/Guardian First Name:  
Parent/Guardian Middle Name:  
Parent/Guardian Last Name:  

Relationship to Student:

Vaccine Required for School Entry
Check Vaccine Declined

Statement of Exemption

I am the student or parent/guardian (if student is under 18 years of age) of the above-named student and am declining the vaccine indicated above due to a religious belief whose teachings are opposed to immunization or a personal belief that is opposed to immunization with the COVID-19 vaccine. 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.