Vermont's Immunization Rule (18 V.S.A. 1123) requires children in child care and students in K-12 schools to be vaccinated unless exempt. This one-page form claims a medical exemption when a vaccine is medically contraindicated or is or may be detrimental to the child's health. The practitioner checks the vaccines, gives the reason and a likely end date, and the family returns it.
A health care practitioner authorized to prescribe vaccines, such as a physician, APRN or PA, completes and signs the whole form on behalf of the child or student.
Download the current version from the source each time; forms change without notice.
Medical Immunization Exemption - Child Care and Schools
Medical Immunization Exemption Form (Child Care and Schools) - Spanish
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.
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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According to Vermont statute, only a health care practitioner authorized to prescribe vaccines may sign it. The practitioner checks only the specific vaccines that are or may be detrimental, gives the reason, and estimates how long the exemption will likely continue.
No. Vermont removed philosophical exemptions in 2016. Besides this medical form, families can use a religious exemption form, which a parent completes each year along with required parent education from the Department of Health.