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Sample Vaccine Exemption
Form
We,
_________________________, hereby state that we have chosen
not to vaccinate our child,_________________ because we are
philosophically opposed to the concept of vaccines.
We
maintain this is a responsible and ethically justifiable
position for the following
reasons:
- -vaccination
is a medical intervention performed on a healthy child
that has the ability to result in injury or death of that
child;
- -the
fact that there can be no guarantee that the deliberate
introduction of killed or live microorganisms into the
body of a healthy child will not compromise the health or
cause the death of that child, either immediately or in
the future;
- -no
predictors have been identified by medical science that
can give advance warning that injury or death may occur in
any individual child;
- -there
are no guarantees that the vaccine will indeed protect the
child from contracting a disease;
- -there
is an absence of adequate scientific knowledge regarding
the way vaccines singly, or in combination, act in the
human body at the cellular and molecular level.
Therefore, we
believe that vaccination is a medical procedure that could
reasonably be termed as experimental each time it is performed
on a healthy child.
Our state law makes
provisions for non-vaccination of children whose parents
object to vaccines for religious or philosophical reasons.
We accept full responsibility for the health of our
child, and because of philosophical conviction, do not wish
our child
vaccinated. In
the event of any infectious condition, our child would of
course remain at home. We
further understand that during the course of an outbreak of
any so called “vaccine preventable disease” would occur at
your facility, our child is subject to exclusion from your
facility for the duration of the outbreak.
_____________________________
____________
Signature
Date
______________________________
____________
Signature
Date
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