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TBS Religious School Vaccination Form

Up to now, Temple Beth Shalom has not believed that a formal vaccination policy for the Kehillat Religious School was necessary due to required vaccinations for children in public schools.  However, there have been recent outbreaks of measles and other preventable diseases caused by the lack of vaccinations. Specifically, the number of measles cases in the U.S. has reached its second-highest level in 25 years. The lack of vaccination presents a clear public health threat.

Safety and public health are priorities for all URJ organizations -- including Temple Beth Shalom. The establishment of a safe environment must therefore include the requirement that all members of the TBS Kehillat Torah Religious School community be adequately immunized against all of the preventable diseases as recommended by the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices.
 
Any individual who attends as a student and/or who teaches in our Kehillat Torah Religious School must have up-to-date, age-appropriate vaccines as recommended by the American Academy of Pediatrics (AAP) and the Center for Disease Control (CDC), or verify they are medically exempt from said vaccines.
 
TBS requires families to submit the below online form verifying their child(ren) have received these vaccinations, or have medical exemptions.

If you would like to view the TBS vaccination policy in full you may read it here on the TBS website. 

Please fill out the form below for each of your students, and if you have any questions, please be in touch with Rabbi Lenette via the temple office at 614-855-4882 or via email at [email protected]

Student #1

DTaP, DT, Td, or Tdap (Diphtheria, Tetanus and Pertussis)
Tdap vaccine required for children over age 11
IPV (Poliovirus)
HIB (Haemophilus influenza type b bacteria)
PCV 13 (Pneumococcal) vaccine
MMR (Measles, Mumps, Rubella) or serologic evidence of immunity.
Varicella vaccine (Varivax for Chicken Pox), or serologic or historical evidence of immunity
Menactra (Meningococcal disease / Meningitis) - required for those age 11 and older
My child has a medical exemption
Rotavirus vaccine
Hepatitis A
Hepatitis B
None of the above
My child has a medical exemption

Student #2

DTaP, DT, Td, or Tdap (Diphtheria, Tetanus and Pertussis)
Tdap vaccine required for children over age 11
IPV (Poliovirus)
HIB (Haemophilus influenza type b bacteria)
PCV 13 (Pneumococcal) vaccine
MMR (Measles, Mumps, Rubella) or serologic evidence of immunity.
Varicella vaccine (Varivax – for Chicken Pox), or serologic or historical evidence of immunity
Menactra (Meningococcal disease / Meningitis) - required for those age 11 and older
My child has a medical exemption
Rotavirus vaccine
Hepatitis A
Hepatitis B
None of the above
My child has a medical exemption

Student #3

DTaP, DT, Td, or Tdap (Diphtheria, Tetanus and Pertussis)
Tdap vaccine required for children over age 11
IPV (Poliovirus)
HIB (Haemophilus influenza type b bacteria)
PCV 13 (Pneumococcal) vaccine
MMR (Measles, Mumps, Rubella) or serologic evidence of immunity.
Varicella vaccine (Varivax – for Chicken Pox), or serologic or historical evidence of immunity
Menactra (Meningococcal disease / Meningitis) - required for those age 11 and older
My child has a medical exemption
Rotavirus vaccine
Hepatitis A
Hepatitis B
None of the above
My child has a medical exemption

Student #4

DTaP, DT, Td, or Tdap (Diphtheria, Tetanus and Pertussis)
Tdap vaccine required for children over age 11
IPV (Poliovirus)
HIB (Haemophilus influenza type b bacteria)
PCV 13 (Pneumococcal) vaccine
MMR (Measles, Mumps, Rubella) or serologic evidence of immunity.
Varicella vaccine (Varivax – for Chicken Pox), or serologic or historical evidence of immunity
Menactra (Meningococcal disease / Meningitis) - required for those age 11 and older
My child has a medical exemption
Rotavirus vaccine
Hepatitis A
Hepatitis B
None of the above
My child has a medical exemption

I, the parent or guardian of the above student(s), warrant the truthfulness of the information provided in this form.

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