AVFCA Medical Exemption Disciplined Doctor Form

All information on this form will be kept completely confidential and will only be shared with Christina Hildebrand and two trusted AVFCA lawyers. Please complete the form below in as much detail as possible, so AVFCA can best assist you.
(Note: all answers are required to submit the form.)
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Your full name

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Your email

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Your child's current grade
PreschoolTK/K1st-6th grade7th grade8-12th grade

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Medical exemption doctor's full name

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Year medical exemption was written

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Have you received a letter from your school revoking your medical exemption? (required)
YesNo

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Have you completed and filed an appeal form?
YesNoN/A

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Which of the following vaccinations has your child ever had?
MMRVaricella (chicken pox)DTaP/TdapPolioHepatitis BNone/Never been vaccinated

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Does your child have titers/antibodies for measles, mumps, rubella, pertussis or varicella?
No, has not been tested or does not have titersYes, measles titersYes, mumps titersYes, rubella titersYes, pertussis titersYes, varicella titers

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Has your child had measles, mumps, rubella, pertussis or varicella naturally?
NoHad measles, mumps and/or rubella naturallyHad pertussis naturallyHad varicella (chicken pox) naturally

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Does your child have special needs and an IEP?
NoMy child has special needs, but no IEPMy child has an IEP

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Please share any other information that you feel would be helpful to understanding your situation.

A Voice for Choice Advocacy will contact you within 48 hours of receiving your information.