Sample Form: It is important that you modify using your own language and beliefs. Check your state laws to make sure you are in conformity. AFFIDAVIT
I/We, ______, Natural Flesh and Blood Human Being(s), state Citizen(s) of the (State or Republic of)______affirm: Be it known to all courts, governments, and other parties that:
Being (a person/people) of Strong Christian Morals, it is against (my/our) Deep, Sincerely Held, Religious Convictions to accept the injection of any foreign substance into (my Body/our Bodies) or the Body of (my/our) Child. This includes, but is not limited to, any and all, Vaccinations, Shots, Tests for Diseases, Oral Vaccines, Epidermal Patches and in any other way that Live or Killed Bacterium, Viruses, Pathogens, Germs, or any other Microorganisms, may be introduced into or upon (my/our) newborn's body.
This written statement to exempt (my/our) newborn from any immunizations, newborn screening, and the Vitamin K shot, because (I/we) hold genuine and sincere personal religious beliefs which are inconsistent with these medical procedures & experimentation. The practice of vaccination and the injection or application of any foreign substance is contrary to (my/our) conscientiously held religious beliefs and practices, and violates the free exercise of (my/our) religious principles.
The Hepatitis-B vaccine supposedly protects against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps (my/our) parental authority to condemn such activity in (my/our) child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of (my/our) faith.
The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert.
http://fdb.rxlist.com/drugs/drug-9003-Aqua-Mephyton+Inj.aspx?drugid=9003&drugname=Aqua-Mephyton+Inj
"The injectable form of vitamin K can rarely cause severe (sometimes fatal) allergic reactions when given by injection into a muscle or vein. Therefore, vitamin K should be injected into a muscle or vein only when it cannot be given by injection under the skin or taken by mouth, or when your doctor has judged that the benefit is greater than the risk. Seek immediate medical attention if you experience symptoms of an allergic reaction such as rash, itching, swelling, dizziness, or trouble breathing."
Potential exists for the newborn to experience hypersensitivity to any component of this medication.
Each milliliter contains: Phytonadione ...... 2 mg or 10 mg
Inactive ingredients:
Polyoxyethylated fatty acid derivative ...... 70 mg
Dextrose...... 37.5 mg
Water for Injection, q.s...... 1 mL
Added as preservative: Benzyl alcohol ...... 0.9%
A conflict arises because (my/our) religious convictions are predicated on the belief that all life is sacred. God's commandment "Thou Shall Not Kill" applies to the practice of injection of carcinogenic substances that can kill.
(We / I) {First and Last name(s)},______as the {(parent (s) /guardian(s)} of (name of newborn child)______are exercising (our/my) rights under the First Amendment of the US Constitution, and [____insert the title and paragraph number of your state law here._____] to receive Religious Exemption from Vaccination, ALL injections, & testing.
Applicable law has been interpreted to mean that a religious belief is subject to protection even though no religious group espouses such beliefs or the fact that the religious group to which the individual professes to belong may not advocate or require such belief. Title VII of the Civil Rights Act of 1964 as amended Nov. 1, 1980; Part 1605.1-Guidelines on Discrimination Because of Religion.
Our legal rights are guaranteed by the free exercise clause of the First Amendment to the U.S. Constitution. Recent court decisions have upheld the rights of individuals seeking exemptions from immunizations based upon personal and religious reasons. On the U.S. Supreme Court level in Frazee V. Illinois Dept. of Security, 489 U.S. 829, it was found that a state may not deny an exemption simply because a person is not a member of a formal religious organization.
The Lord Jesus Christ and Our Creator are the only source of protection of (my body/our bodies) and that of (my/our) family that (I/we) can accept.
(I/We) affirm that vaccination & injections of any foreign substances and proteins conflict with (my/our) religious beliefs as stated above. Therefore, (I/we) would request that you accommodate (my/our) religious beliefs and practices by exempting (my/our) newborn child from any vaccinations, injections and testing of any kind.
Rest assured that (my family and I/our family) do practice a form of immunization that keeps our immune systems strong and is in keeping with Biblical principles.
The use of notary below is for identification only, and such use does NOT grant any jurisdiction to anyone.
Subscribed and sworn, without prejudice, and with all rights reserved, (Print Name Below)
______,
Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.
______
Signature of Affiant
ACKNOWLEDGMENT
state of ______
county of ______:
On this ______day of ______, 20___, before me
personally appeared ______, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he executed the same as his free act and deed, for the purposes therein set forth.
______
(Notary Public)
My Commission Expires ______, 20___