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CT PreK Religious Exemption In Process Declaration

This DPH declaration applies only to preschool and prekindergarten students who had a religious exemption on file before April 28, 2021. With it, the child's provider confirms the student qualifies and states the clinical reasons for vaccinating on an alternative schedule rather than the Commissioner's standard Schedule for In Process Required School Immunizations.

Who completes it

The child's provider, licensed as a physician (MD or DO), PA or APRN with a Connecticut license number, completes the demographics (Part 1), checks the clinical reasons (Part 2) and signs (Part 3).

Submitting and payment

How to submit it
Give it to the preschool or school with a copy of the current immunization record and a detailed catch-up schedule listing which vaccines will be given and when.
Who pays
The form carries no fee or billing code.

Good to know

  • Before signing, the provider must have received a copy of the student's religious exemption statement from the preschool program, dated before April 28, 2021.
  • Part 2 reasons include family history of autoimmune disorder or vaccine reaction, genetic predisposition shown by testing, a prior documented reaction, or another specified condition.
  • If the student does not meet the criteria, use the standard Healthcare Provider's Certification of In Process Required School Immunizations instead.
  • The current version is dated 1/31/2023. Public Act 21-6 repealed non-medical exemptions in Connecticut.

Get the official form

Download the current version from the source each time; forms change without notice.

Healthcare Provider's Declaration of In Process Required School Immunizations for PreK or Pre-School Students Subject to Religious Exemption Prior to April 28, 2021

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Which students qualify for the Connecticut PreK religious exemption declaration?

Only a student who, before April 28, 2021, was enrolled in a preschool or other prekindergarten program and was exempt from immunization requirements based on a religious statement submitted to that program. The provider confirms this by obtaining a copy of the dated religious exemption statement from the program.

What must be attached to the Connecticut PreK declaration?

A copy of the student's most current immunization record and a detailed catch-up schedule showing which vaccines the child will receive and when. The provider also checks the clinical reasons for the alternative schedule in Part 2 and signs Part 3.