Non-Medical Exemption (Waiver) Electronic Signature Attestation

 

MICHIGAN CARE IMPROVEMENT REGISTRY (MCIR)

The Michigan Care Improvement Registry (MCIR) provides a place for your or your child’s immunization history to be stored confidentially. MCIR is used as a tool and can help providers accurately determine if a vaccine is needed based on the recorded immunization history. MCIR collects and combines immunization information for Michigan residents of all ages. Information in MCIR is confidential and all MCIR users are held to strict security and confidentiality requirements.

Non-Medical Exemptions (Waiver) are completed electronically in MCIR and the school will have immediate access to completed exemptions for those school age children that are obtaining a non-medical exemption from any school required immunizations. If your child does not have a MCIR, one will be created.

You have the right to object to having your or your child’s immunization(s) reported to MCIR, which is otherwise required by MCL 333.9209. Remember, if immunization information is not stored in MCIR, your provider might not have access to a complete immunization history, and it will be essential for you to keep your and/or your child’s immunization record for future medical visits, schooling or possible employment opportunities. 

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 Kalamazoo County Health and Community Services Department (“KCHCS”). 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 KCHCS 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 at hcsmiwaiv@kalcounty.gov to schedule an in-person appointment with a nurse to physically sign the non-medical exemption (waiver) form. 

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: 1Kalcountywaiver!

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 1Kalcountywaiver!