Electronic Signature Attestation

Non-Medical Exemption (Waiver) Electronic Signature Attestation

Mid-Michigan District Health Department
Parent/Legal Guardian Information
Parent/Legal Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number for Texting
Please enter a valid phone number.
Email
example@example.com

Child(ren) Information
List the Legal First and Last Name for each child you are signing for (as listed in MIWAIV online learning platform):*
Electronic Signature Agreement

By selecting the “I Accept” button below, you hereby execute this Agreement electronically. You acknowledge and agree that your electronic signature constitutes your legally binding signature and is the full legal equivalent of your handwritten signature. By selecting “I Accept” through any device, mechanism, or method, you expressly consent to be bound by all terms, conditions, and obligations set forth herein. You further acknowledge that your electronic signature (hereinafter, the “E-Signature”) shall be deemed valid and enforceable to the same extent as a signature affixed in ink to a physical document.

You additionally agree that no certification authority, digital certificate, or other third-party authentication is required to validate your E-Signature, and that the absence of such certification or verification shall in no way diminish or impair the enforceability of your E-Signature or any agreement entered into between you and the Mid-Michigan District Health Department (“MMDHD”). You affirm that you are duly authorized to execute this Agreement on your own behalf or on behalf of the individual you are legally permitted to represent.

Furthermore, by affixing your E-Signature below, you attest that you have viewed the vaccine education modules available within the MIWAIV platform. You also authorize MMDHD staff to enter or record your name, as Parent/Legal Guardian, into the Michigan Care Improvement Registry (MCIR) as a valid signature for purposes of completing the non-medical exemption (waiver) form required for school or childcare enrollment.

By selecting the “I Do Not Accept” button below, you decline to provide an electronic signature. In such case, your electronic signature will not be accepted, and you will be required to contact our office to schedule an in-person appointment with a nurse to physically sign the non-medical exemption (waiver) form. Please select option 5, then option 2 when calling.

Clinton County 989-224-2195
Gratiot County 989-875-3681
Montcalm County 989-831-5237

A copy of this Agreement will be emailed to you at the email address supplied above. It will require a password to access the signed PDF. Your password (case sensitive) is: 1Waiver@MMDHD
Please select your option as to the terms stated above:*

I AcceptI do not Accept
Parent/Legal Guardian Signature*

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If you have provided an email address above, a secured PDF copy of your signed document will be sent to you. A password will be required to open the PDF.

Your password to access the PDF is 1Waiver@MMDHD
Should be Empty:

Non-Medical Exemption (Waiver) Electronic Signature Attestation

Parent/Legal Guardian Information

Child(ren) Information