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Vaccine Exemption Form










Personal Belief Vaccine Exemption Form


Please be informed that we are opting for a personal belief exemption from vaccinating our
children. 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.

With any forced vaccination, these are the fundamental rights being violated:
1.      An unconstitutional expansion of the power of the federal government.
2.      An unconstitutional delegation of power to a public-private partnership.
3.      An unconstitutional and destructive intrusion into the patient-physician and parent-child relationships.
4.      A violation of the Nuremberg Code in that they force individuals to have medical treatment against their will, or to participate in the functional equivalent of a vast experiment without fully informed consent.
5.      A violation of rights to free speech and to the practice of one's religion (which may require one to keep oaths).

Medical basis for vaccine exemption

Our sound decision to forego vaccinations for personal reasons is based in part on the testimonies of the following medical authorities:

"Live virus vaccines against influenza or poliomyelitis may in each instance produce the disease it intended to prevent . . . . the live virus against measles and mumps may produce such side effects as
encephalitis."
Jonas and Darrell Salk, Creators of the Salk Polio Vaccine, Science Magazine, March 4, 1977

"In regions in which there is no organized vaccination of thepopulation, general paralysis is rare. It is impossible to deny a connection between vaccination and the encephalitis which follows it."
Journal of the American Medical Association July 3, 1926, p.45

"No batch of vaccine can be proved safe before it is given to children." Surgeon General of the United States Leonard Scheele, addressing an AMA convention in 1955

"The only safe vaccine is a vaccine that is never used." Dr. James A. Shannon, National Institutes of Health

"In recent years many men and women in the prime of life have dropped dead suddenly.. I am convinced that some eighty percent of these deaths  are caused by the inoculation or vaccination they have undergone. They are well known to cause grave and permanent disease to the heart. The
coroner always hushes it up as ‘natural causes."
Dr. Herbert Snow - Senior Surgeon at the Cancer Hospital of London

"Immunization programs against flu, measles, mumps and polio may actually be seeding humans with RNA to form proviruses which will then become latent cells throughout the body. . . they can then become activated as a variety of diseases including lupus, cancer, rheumatism and arthritis."
Robert W. Simpson, M.D., of Rutgers University Addressing the annual American Cancer Society Science Writers Seminar

"The injection of any serum, vaccine, or even penicillin has shown a very marked increase in the incidence of polio, at least by 400%." Dr. William Koch

"My honest opinion is that vaccine is the cause of more disease and suffering than anything I could name. I believe that such diseases as cancer, syphilis, cold sores and many other disease
conditions are the direct results of vaccination. Yet, in the state of Virginia, and in many other states, parents are compelled to submit their children to this procedure while the medical profession not only receives its pay for this service, but also makes splendid and prospective patients for the future."
Dr. Henry R. Bybee, M.D.

"The vaccination practice, pushed to the front on all occasions by the medical profession through political connivance made compulsory by the state, has not only become the chief menace and the greatest danger to the health of the rising generation, but likewise the crowning outrage upon the personal liberties of the American citizen; compulsory vaccination, poisoning the crimson currents of the human system with brute-extracted lymph under the strange infatuation that it would prevent smallpox, was one of the darkest blots that disfigured the last century."
J. M. Peebles, M.D.

"In mass vaccination programs, it is common practice to omit or ignore such information in presenting the case for vaccination to the public. There is a tendency to let the 'experts' make the decisions, after which they summarize the evidence with such press release statements as 'absolutely safe' and other statements designed not to educate, but to inspire absolute confidence. We point out that the tendency of a mass vaccination program is to 'herd' people. A mass vaccination program carries a built-in temptation to oversimplify the problem, to exaggerate the benefits, to minimize or completely ignore the hazards, to discourage or silence scholarly, thoughtful and cautious opposition, to create an urgency where none exists, to whip up an enthusiasm among citizens that can carry with it the seeds of impatience, if not intolerance, to extend the concept of the police power of the state far beyond its proper limitation, to assume simplicity when there is actually great complexity, to continue support of a vaccine long after it has been discredited, and to ridicule honest and informed dissent."
Clinton Miller, in testimony before the US House of Representatives

"Take all the profit out of manufacturing and administration of serums and vaccines and they would soon be condemned, even by those who are now using them."
Dr George S. White, M.D.

"Since people cannot be vaccinated against their will, the biggest job of a health department is always to persuade the unprotected people to get vaccinated. This we attempted to do in three ways, education, fear, and pressure. We dislike very much to mention fear and pressure, yet they accomplish more than education because they work faster than education, which is normally a slow process. During the months of March and April, we tried education and vaccinated only 62,000. During May we made use of fear and pressure and vaccinated 223,000 people."
Dr John Keller

"The vaccine business has continued to thrive in spite of its disastrous failure, for the mere reason that it nets millions of dollars for the promoters, and this buys power with governments and propaganda control over the masses."
Eleanor McBean, Ph.D.

"Faced with a patient who has all the signs and symptoms of a particular disease, from which they have been 'protected' by immunisation, it is obviously difficult to make the diagnosis they would have made if faced by such a case in an unvaccinated person. By calling the disease something else, they are protecting their belief system, the integrity of their decision to vaccinate, and to help save the public from having doubts about the efficacy of their methods. Re-diagnosis is a real phenomenon, and it happens all the time. In the case of diphtheria this was rampant. In some epidemics, the figure of
re-diagnosis reached 60% of cases."
Leon Chaitow

"The greatest threat of childhood diseases lies in the dangerous and ineffectual efforts to prevent them through mass immunisation."
Dr R. Mendelsohn - Paediatrician

"There is a great deal of evidence to prove that immunisation of children does more harm than good."
Dr A. Morris - Research Scientist

"There is now sufficient evidence of immune malfunction following current vaccination programs, to anticipate growing public demands for research investigation into alternative methods of prevention of
infectious disease."
Drs H. Buttram and J. Hoffman - "Vaccinations and Immune Malfunctions"

"In addition to the many obvious cases of mortality from these practices, there are also long-term hazards which are almost impossible to estimate accurately...The inherent danger of all vaccine procedures should be a deterrent to their unnecessary or unjustifiable use."
Sir Graham Wilson - "The Hazards of Immunisation"

"Every vaccine carries certain hazards and can produce inward reactions in some people...In general, there are more vaccine complications than is generally appreciated."
Professor G. Dick - London University

"Laying aside the very real possibility that the various vaccines are contaminated with animal viruses and may cause serious illness later in life, such as multiple sclerosis, cancer, leukaemia, kreutzfeld-jacob
disease, etcetera, we must consider whether the vaccines really work for the intended purpose."
Dr W. Douglas - Cutting Edge, May 1990

"All vaccination has the effect of directing the three values of the blood into or toward the zone characteristics of cancer and leukaemia...Vaccines do predispose to cancer and leukaemia."
Professor L. Vincent - founder of Bioelectronics

"Many here voice a silent view that the Salk and Sabin Polio Vaccines, being made from monkey kidney tissue, has been directly responsible for the major increase in leukaemia in this country."
Dr F. Klenner - Polio Research Scientist

"When immunisations were given at three months old, the peak of cot deaths was 3 to 4 months. We are now told that the peak is 2 to 3 months, and this change occurred just after they began immunisations at two months. I am certain that there is some connection between cot deaths and immunisation."
Sister J. Lubke - Author of "I Had No Say"

"My suspicion, which is shared by others in my profession, is that the nearly 10,000 SIDS deaths that occur in the U.S.A. each year are related to one or more of the vaccines that are routinely given to children. Thepertussis vaccine is the most likely villain, but it could also be one or more of the others."
Dr R. Mendelsohn - Paediatrician

"The worst vaccine of all is the whooping cough vaccine...It is responsible for a lot of deaths and for a lot of infants suffering irreversible brain damage. In susceptible infants, it knocks their immune systems about, leading to irreparable brain damage, or severe attacks, or even deaths from diseases like pneumonia or gastro-enteritis and so on." "It was similar with the measles vaccination. They went through Africa, South America and elsewhere, and vaccinated sick and starving children...They thought they were wiping out measles, but most of those susceptible to measles died from some other disease that they developed as a result of being vaccinated. The vaccination reduced their immune levels and acted like an infection. Many got septicaemia, gastro-enteritis, etcetera, or made their nutritional status worse and they died from malnutrition. So there were very few susceptible infants left alive to get measles. It's one way to get good statistics, kill all those that are susceptible, which is what they literally did."
Dr A. Kalokerinos

"No batch of vaccine can be proved to be safe before it is given to children."
Dr Leonard Scheele - Surgeon General

"There is no sound basis for the assumption that every child or infant must be innoculated with every available vaccine; on the contrary, there may be a valid reason for omitting any or all available antigens...The incidence of vaccine-induced morbidity has increased alarmingly. The professions must re-evaluate the principles, purposes, and hazards of immunisation and re-assess current procedures."
From an article in the International Medical Digest

"Babies may and do die for up to 25 or more days after vaccination, as a direct consequence of the toxic effects of the vaccines. It has been confirmed that a great number of babies, if not all, suffer a clinical
or sub-clinical encephalitis shortly after being injected a variety of vaccines. The great increase in a large array of brain-related conditions in the United States closely followed chronologically mandatory administration of vaccines en masse in that country.  These conditions include autism, learning difficulties, cerebral palsy, dyslexia, hyperactivity, deafness, blindness, and permanent brain damage. Our conclusion is that if vaccination were to be suspended, the cot death rate would be at least halved."
Drs V.Scheibner and L.Karlson

Child's name: ________________________

Respectfully submitted on this date: _________

SIGNED:                                                                                                 SIGNED:

___________________________________                       ______________________________
Parent or Legal Guardian                                                                     Parent or Legal Guardian



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