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Annual Human Papillomavirus (HPV) Vaccination Opt-Out Certificate

Instructions for completing HPV Vaccination Opt-Out Certificate (Return Completed Certificate to school, keep copy of information sheet for your reference)

Section 1: Before signing, read the information sheet on HPV Vaccine.

Section 2: Parent/guardian or student (if 18 years of age or older) sign and date after reading the HPV Information Statement.

Section 2: Student Information

School Name*

Answer Required

Student Name*

Answer Required

Date of Birth*

Answer Required

Street Address*

Answer Required

City, Zip Code*

Answer Required

Home Phone

Answer Required

Mobile Phone*

Answer Required

Email Address*

Answer Required

Name and Address of Health Care Provider*

Answer Required

City*

Answer Required

Zip Code / Postal Code*

Answer Required

Health Care Provider Phone:*

Number Required

Annual Opt-Out for Human Papillomavirus (HPV) Vaccine*

I have received and reviewed the benefits of the HPV vaccine in preventing cervical cancer and genital warts if it is given to preteen girls and boys. After reviewing the information about the risk of contracting HPV and the link between HPV and cervical cancer, other cancers and genital warts, I have decided to opt-out of the HPV requirement for the above named student. I know that I may revisit this decision at any time during the recommended vaccination window and complete the required vaccinations. Please provide electronic signature and date.

Answer Required

Name of Parent/Guardian or Student if 18 years or Older. Date*

Answer Required

Confirmation Email

Confirmation Email *

Email Required