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Forced Vaccination Exemption Form

We, (first and last name goes here) parents and legal guardians residing at: (legal address goes here). Hereby state that we have chosen not to vaccinate our children: (your children first and last name goes here) because we are philosophically and scientifically opposed to the concept of unwanted and forced vaccination of our children.

We are convinced and maintain that our action to save our children health, wellbeing and safety is responsible and ethically justifiable position for the following factual reasons:

1. Vaccination is a highly risky and unproven medical intervention, performed on healthy children, capable of causing serious injuries and or children’s death.

2. The fact that there are no guarantees, which the deliberate introduction of dead or living microorganisms into the body of healthy children will not compromise the health or cause long-term serious health risks, diseases and death of the vaccinated children, either immediately or in the future.

3. No predictors have been identified by the medical science, which can give advanced warning that injury or death may occur in any individual vaccinated child.

4. There are no guarantees that the vaccine will indeed protect children from contracting any diseases and that vaccines will not cause learning disability, violent tendency and many other psychological and physical health risks and deadly diseases.

5. In the absence of adequate scientific knowledge regarding the deadly microorganisms put into vaccines singly, or in combination, causing unknown and unpredictable behavioral patterns in the human body at the cellular and molecular level.

6. Fact is that like any medication, vaccines cause many side effects. The most reported common side effects are: autism, attention deficit disorder, learning disability, erratic behavior, mental retardation, hypertension, violent behavior and death had occurred to the vaccinated children.

Therefore, we believe that vaccination is a medical procedure, which could reasonably be termed as experimental each time it is performed on a healthy child.

The U.S. Constitution and the State of (YOUR State Name Goes Here) law provides provisions for non-vaccination of children whose parent’s object to vaccines for religious, or philosophical reasons. We accept full responsibility for the health of our children, and because of philosophical conviction, we do not wish our children to be vaccinated. In the event of any infectious condition, our child would of course remain at home to recover. We further understand that during the course of an outbreak of any so called “vaccine preventable disease” would occur at the school’s facility, our children will be subject to exclusion from the school’s facility for the duration of the outbreak.


Signature - Father, or Legal Guardian
Signature - Mother, or Legal Guardian
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