Non-Medical Exemption (Waiver) Electronic Signature Attestation
District Health Department 4
Parent/Legal Guardian Information
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Alpena
Cheboygan
Montmorency
Presque Isle
Email Address
*
example@example.com
Mobile Phone Number for Texting
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list the Legal First and Last Name for each child you are signing for (As listed in MIWAIV online learning platform)
*
Back
Next
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 District Health Department 4 (“DHD4”). 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 DHD4 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 call 1-800-221-0294 and select the county you reside in, on the next menu select option 2. A copy of this Form & Agreement will be available to you for download on the "Thank You" page once you select submit request. It will require a password to access the signed PDF. Your password (case sensitive) is: 4Waiver@DHD4
Please select your option as to the terms stated above:
*
I Accept
I do NOT Accept
Parent/Legal Guardian Signature
*
Notice:
A secured PDF copy of your signed document will available for to download once you select "Submit Request" on the Thank You page. A password will be required to open the PDF. Your password to access the PDF is 4Waiver@DHD4
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit Request
Submit Request
Should be Empty: