Immunization Record & Exemption Statement

Official school form

Records your child's immunization status or your exemption on file, as required for school attendance in Oklahoma.

Requirement

Oklahoma requires every enrolled student to have an immunization record on file or a completed exemption statement. A copy of the state immunization card, clinic printout, or physician letter should be delivered to the school office.

Exemptions

Families may claim a medical, religious, or personal exemption. An exemption on file is honored without question; in the event of a communicable disease outbreak, exempted students may be excluded from campus for the duration of the health department's exclusion period.

Information to complete

Student full name *

Student date of birth *

Immunization status *

Up to date — record attached or on file
In progress — schedule attached
Exemption claimed

If claiming an exemption, which type

Not applicable
Medical
Religious
Personal

Where the record will come from (clinic, health dept., physician)

Notes

I certify the immunization information provided is accurate and I will deliver supporting documentation to the school office.

Parent / guardian signature

Date

Solomon Heights Academy3200 NW 48th Street, Oklahoma City, Oklahoma 73112Immunization Record & Exemption Statement

Return completed forms to the school office at 3200 NW 48th Street, Oklahoma City, Oklahoma 73112.