If a school division superintendent demands that a homeschool family, whether under notice of intent or religious exemption from school attendance, provide proof that they are not in violation of state immunization laws, the member family may use this form. When properly filled out and signed in front of a notary, this form becomes an affidavit which can be transmitted to the division superintendent to satisfy his or her demand for documentation about a child’s immunization status pursuant to Virginia Code §22.1-271.4.