Vaccine Refusal 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.
______________________________ Date ____________
______________________________ Date ____________
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