Sample Form: It is important that you modify and use your own
language and beliefs. Check your state laws to make sure you
are in conformity.
AFFIDAVIT
I, _________________________, state Citizen of the__________________ Republic affirm:
Be it known to all courts, governments, and other parties that:
Being a person of Strong Christian Morals, it is against my Deep, Sincerely Held, Religious
Convictions to accept the injection of any foreign substance into my Body. 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 body.
This written statement to exempt myself from the immunization requirement, and the Mantoux
(PPD) Tuberculin Test, because I hold genuine and sincere personal religious beliefs which
are inconsistent with these medical procedures and experimentation. The practice of
vaccination and the injection of any foreign substance is contrary to my conscientiously held
religious beliefs and practices, and violates the free exercise of my religious principles.
The attenuated virus used to produce the Rubella vaccine (RA27/3) was obtained from an
aborted fetus and then cultivated on fetal tissue from another aborted baby (WI-38), and is
also in the rubella portion of the MMR-II vaccine. The Chickenpox vaccine containing WI-38,
MRC-5 and Hepatitis-A vaccine (MRC-5) were obtained from human babies that were
electively aborted. A conflict arises because my religious convictions are predicated on the
belief that all life is sacred. God's commandment "Thou Shall Not Kill" applies to the
practice of abortion. The acceptance of these vaccines promotes abortion and violates the
Sixth Commandment of "Thou Shall Not Kill". The Hepatitis-B vaccine protects against a
disease that is only transmitted through multiple sexual partners or street IV drug users. The
acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct
contradiction to the teachings of my faith.
I, {First and Last name}, am exercising my rights under the First Amendment of the US
Constitution and [insert State college exemption statute here] to receive Religious
Exemption from Vaccination & 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 and that
of my family that I can accept.
I affirm that vaccination & injections of foreign proteins conflict with my religious belief as
stated above. Therefore, I would request that you accommodate my religious beliefs and
practices by exempting me from the college vaccination and TB testing requirement.
Rest assured that I do practice a form of immunization that keeps my immune system 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)
_______________________________________________________________,
Printed Name
_______________________________
Signature
ACKNOWLEDGMENT
state of _____________________,
county of _________________:
On this _______ day of ______________, 201__, 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___