Feel free to use this letter as is, or personalize to fit your needs.
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It reads as below:
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Immunization Exemption Letter
(Current Date 00/00/2014)
To Whom It May Concern:
Re: Religious Exemption
I, ___________________________________, being the legal guardian of ________________________________ object to the immunization requirements as outlined by the Department of Health of the Commonwealth of Pennsylvania as defined in 28 PA. CODE CH.23 on the basis of a strong moral or ethical conviction similar to a religious belief as outlined in section § 23.84 Exemption from immunization.
If you need a copy of the School Immunizations Rules and Regulations [28 PA. CODE CH. 23] for your records, I will be happy to provide you a copy.
§ 23.84. Exemption from immunization. [28 PA. CODE CH.23]
(a) Medical exemption. Children need not be immunized if a physician or the physician's designee provides a written statement that immunization may be detrimental to the health of the child. When the physician determines that immunization is no longer detrimental to the health of the child, the child shall be immunized according to this subchapter.
(b) Religious exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.