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Philosophical/Strong Moral Ethical Conviction or Religious Exemption FormTo: Pennsylvania Leadership Charter School:I am the parent/guardian of: _______________________________________________Grade: ____________Please Check One: FORMCHECKBOX I object to the following procedures for my child. (Must be contrary to the religious beliefs of the parent or guardian of the child. May also include a strong moral or ethical conviction similar to a religious belief.) Circle applicable procedures:Immunizations Medical Examinations Dental Examinations FORMCHECKBOX I do not have a moral, ethical, or religious conviction regarding the above procedures, and therefore do not seek an exemption from these medical procedures for my child.Parent/Guardian Print Name:______________________________________________________________________Parent/Guardian Signature: ______________________________________________________________________Date: __________________ ................
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