Banjul American International School

Atlantic Road, Fajara

Serrekunda, The Gambia
Tel: (220) 219-3800
Director@BAISGambia.org

VACCINATION RECORD EXEMPTION

A parent or guardian wishing to request an exemption from the enrollment requirement to provide
immunization records for their child(ren) must submit this completed form to register that choice.
REQUEST for EXEMPTION
I request exemption of the child(ren) named below from the requirement to provide a record of
standard vaccinations in order to enroll in Banjul American International School.
For student: SULAYMAN IBN MALAKHI KAINE
Date of Birth: 01 March 2020

Select the exemption type and the vaccinations from which you wish your child(ren to be exempt):
EXEMPTION TYPE:
_____ Personal/Philosophical Exemption
_____ Religious Exemption (Which religion? __________________________)
VACCINATION EXEMPTIONS REQUESTED FOR:
● COVID ● Measles, mumps, & rubella ● Pertussis (whooping cough)
● Diphtheria (may not be exempted for personal/ ● Tetanus
philosophical reasons)
● Hepatitis B ● Pneumococcal ● Varicella (chickenpox)
● Hib ● Polio ● Yellow Fever

PARENT/GUARDIAN DECLARATION
● I understand the benefits and risks of immunizations.
● Immunization is one of the best ways to protect people from getting and spreading
diseases that may result in serious illness, disability, or death.
● A person who has been exempted from a vaccination is considered at risk for the disease
or diseases for which the vaccination offers protection.
● Vaccine-preventable diseases still exist, and can spread quickly in school settings.
● One or more of the required vaccines are in conflict with my personal, philosophical, or
religious beliefs.
● I understand that if an outbreak of vaccine-preventable disease occurs for which my child
is exempted, my child may be excluded from school for the duration of the outbreak.
● I understand that this exemption does not exempt my child(ren) from other required
health protocols the school may enact to reduce health risks or spread of disease.
● The information on this form is complete and correct.
● My signature below indicates my acknowledgement/agreement with the points above.
Parent/Guardian Name (print):____________________________________
Parent/Guardian Signature: ____________________________________
Date: _______________
RECEIVED by BAIS
Director Signature: _____________________________ Date: ________________