South Tangerang, July 19, 2021

No.: 001/B/ICM/SMP-SMA/VII/2021
Subject: Student Vaccination

Dear Parents of,

ICM Middle and High School Program

Assalamu’alaikum Warahmatullah Wabaraakatuh.

Praise Allah SWT, who has given us various pleasures to do our daily activities well. Prayers and
greetings are continuously poured out to the Prophet Muhammad SAW, family, friends, and
followers. Aamiin Yaa Rabbal'alamiin.

Based on the Circular Letter of the Director of Disease Prevention and Control of the Ministry of
Health of the Republic of Indonesia Number: HK.02.02/I/1727/2021 dated June 30, 2021, concerning
Phase 3 Vaccination for Vulnerable Communities and Other General Publics and Implementation of
Covid-19 Vaccination for Children Aged 12-17 Year. Therefore, we would like to inform you that
vaccination will be carried out in ICM Secondary School (Middle and High School) Program as part
of the Offline Learning (PTM) requirements and one of the efforts to stay healthy during this covid
19 pandemic.

We appreciate you filling out the statement letter that is attached to this announcement letter. Then,
please scan or take a picture of it and send it on the link: https://bit.ly/Vaksin-SMP-SMAICM lastest
by July 22, 2021.

Should you have any questions, please feel free to email us at schooladmin@icm.sch.id. Last but
not least, thank you for your continuous support. Stay safe and healthy.

Wassalamu’alaikum Warahmatullah Wabaraakatuh.

Acknowledged by Your sincerely,

INSAN CENDEKIA MADAN!

Bambang Eko Nugroho Dani M. Ramdani Chabib Mustofa
Managing Director High School Principal Middle School Principal
 SURAT PERNYATAAN VAKSINASI
Yang bertanda tangan di bawah ini:
Nama Orangtua : .............................................................................................................................................
Alamat Orangtua : .............................................................................................................................................
.............................................................................................................................................
No. Telp dan Email : .....................................................dan..................................................................................

Selaku orang tua / wali dari siswa:

Nama Siswa : .............................................................................................................................................
Tempat/Tgl. Lahir/Usia : ........................................./................................./.................................................................
Kelas : .............................................................................................................................................
Riwayat Komorbid : Tidak / Ada (*), Jenis: ……………………………………………………………………………..

Dengan ini menyatakan:

1. Selaku orangtua atau wali saya MEMBERIKAN IZIN / TIDAK MEMBERIKAN IZIN(*) anak saya untuk
mengikuti program vaksinasi anak usia 12-17 tahun bantuan dari Pemerintah di SMA Insan Cendekia Madani.
Bagi orangtua atau wali yang TIDAK MEMBERIKAN IZIN:
Alasan:
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….

2. Bersedia mematuhi ketentuan dan aturan yang berlaku didalam mendukung terselenggaranya pembelajaran
tatap muka bagi seluruh warga sekolah, dimana salah satunya yaitu tidak bisa mengikuti PTM (jika sudah
diizinkan Pemerintah) jika belum divaksin.

Demikian pernyataan ini saya buat dengan sadar dan tanpa paksaan dari pihak manapun dan untuk digunakan
sebagaimana mestinya.

…………………………….., …..………………. 2021

Yang Membuat Pernyataan,

(……………………………………)
Ttd dan nama jelas Orangtua/Wali

*Coret yang tidak perlu, dan tulis alasan jika tidak memberikan izin.