[heading "Immunization Exemption Letter"]

    *your name

    [text_content "To Whom It May Concern:"]

    [text_content "Re: Pennsylvania Vaccination Requirements - Religious Exemption"]

    [text_content "We,"]

    *Your Name

    [text_content "Being the Legal Guardians of"]

    [text_content "of"]

    *Childs Name

    [text_content "object to the Immunization"]

    [text_content "Requirements as outlined by the Department of Health of the Commonwealth of Pennsylvania as defined in 28 PA. CODE CH.23 on the basis of a religious belief/strong moral or ethical conviction outlined in section 23.84 Exemption from Immunization."]

    Parent/Guardian Sig

    Parent/Guardian Date

    [text_content "23.84. Exemption from immunization. 28 PA. CODE CH.23"]

    [text_content "Source: http://www.pacode.com/secure/data/028/chapter23/s23.84.html"]

    [text_content "(a) Medical Exemption. Children need not be immunized if a physician or the physician's designee provides a written statement that immunization may be detrimental to the health of the child. When the physician determines that immunization is no longer detrimental to the health of the child, the child shall be immunized according to this subchapter"]

    [text_content "(b) Religious Exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief."]