GEORGIA - IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)
IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)Georgia
Current Statutes & Laws: http://www.909shot.com/state-site/Georgia.htm
Medical & Religious (notarization required on exemption for school children)
Exemptions apply to a child whose parent or legal guardian objects to immunization of the child on the grounds that the immunization conflicts with the religious beliefs of the parent or guardian.
PDF documents (.pdf)
A special reader, Acrobat Reader software for Windows(TM), Macintosh(TM), MS-DOS(TM), SGI(TM), and Sun(TM) is required and is available free from Adobe.
Download Acrobat Reader:
Exemption Letters & Forms...
For those who are planning a hospital birth but want to evade invasive routine post natal procedures such as a Hep B shot, vitamin K injection, newborn screening, or the application of silver nitrate in the newborn's eyes, a very specific birthing plan must be submitted to the hospital in advance of the birth. Hospital staff must be informed, in advance, of your needs, wants and desires where your baby and birthing experience are concerned. The same applies to midwives.
Birth Exemptions:
Religious Exemption from newborn screening allowed under
Ga. Code Ann. § 31-12-7
31-12-7.
(a) The department, or its successor agency or department, shall adopt and promulgate appropriate rules and regulations governing tests for phenylketonuria, sickle cell anemia, and sickle cell trait so that as nearly as possible all newborn infants who are susceptible or likely to have phenylketonuria, sickle cell anemia, or sickle cell trait shall receive a test for phenylketonuria, sickle cell anemia, or sickle cell trait, or all of such conditions as soon after birth as successful testing and treatment therefore may be initiated; provided, however, that this Code section shall not apply to any infant whose parents object thereto on the grounds that such tests and treatment conflict with their religious tenets and practices.
http://www.ganet.state.ga.us/cgi-bin/pub/ocode/ocgsearch?docname=OCode/G/31/12/7
Newborn Screening for Metabolic and Sickle Cell Disorders Program
Screening: Parents Refusal
Religious grounds are the only valid reason for refusal of newborn screening. If a parent objects to testing based on religious grounds, a hospital official is to inform the parent of the consequences of refusal (possible infant death or retardation) and require the parent to complete a statement indicating their declination of newborn screening for religious reasons. This signed refusal should be retained in the record of the physician, midwife or individual attending the delivery.
http://health.state.ga.us/programs/nsmscd/screening_refusal.aspIMPORTANT! Please download this if you're expecting a child or know someone who is!
Georgia Newborn Screening Manual for Metabolic Diseases & Hemoglobinopathies
A Practitioner’s Guide
Older Guide (has the sample refusal form)
(.pdf)
http://health.state.ga.us/pdfs/familyhealth/ganewbornscreening.98.pdfOn page 9 is the METABOLIC AND HEMOGLOBIN SCREENING NOTICE
I, the parent of Baby __________________________, understand that Georgia law requires that all infants born in Georgia have the Newborn Screening test performed, unless the parent’s object to such testing for religious reasons.
This proves to the hospital that religious exemption is allowed for newborn screening in Georgia.
Page 9 is a SAMPLE form. We have page 9 without the SAMPLE stamp.
Email us at Exemptions Contact Page for a typed Word or PDF document for above letter. Put Georgia METABOLIC AND HEMOGLOBIN SCREENING NOTICE (Page 9) in the subject line.
You can and should use this along with the Model Birth Plan letters.
New Guide
Newborn Screening Manual for Metabolic Diseases & Hemoglobinopathies
(.pdf) http://health.state.ga.us/pdfs/familyhealth/nsmscd/nsmscd.manual.04.pdfNo sample form in the new guide. See old guide above to view sample refusal form.
Vitamin K Injection...
The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert.
(.pdf) http://www.fda.gov/medwatch/SAFETY/2003/03Feb_PI/AquaMEPHYTON_PI.pdf"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."The package insert should be printed out and used along with the model birth plan letter, the page of the manual that mentions religious exemption from newborn screening, and your exemption letter or AFFIDAVIT. This shows the hospital or birthing center that you are aware of the risks of Vitamin K injection, and that they should be too.
fatalities=death
Email us at Exemptions Contact Page if you want a birth exemption AFFIDAVIT typed out for Georgia.
Alternatives to Vitamin K Prophylaxis...
Although oral vitamin K is not licensed for use as a drug by the FDA, drops for oral administration are available. Typically, one drop contains 2 mg. of vitamin K. Contact a midwife in your area, or a birthing supply company (such as birthwithlove.com), or Scientific Botanicals (206 527-5521) where your health care provider can order liquid vitamin K directly.
Here's another much safer alternative that your chiropractor or naturopath can order for you.
http://www.bioticsresearch.com/Products/BioK.htm
A good organic whole food diet along with lots of leafy green vegetables is all that is necessary to prevent vitamin K deficiency in newborns.
Sample Vaccine Letters From this website... http://www.vaccines.bizland.com/letters.htm
Most states now require the Hepatitis B vaccine for newborns. Many parents are also cornered by emergency room personnel during accident visits. Hospitals nationally are under pressure to utilize every opportunity to score a "hit." If your pediatrician understands your views, get him involved with the hospital. As a last resort, protect your right to receive quality care in the following manner. (Usually, you'll never find anybody in the hospital to sign this simple form):
"I certify that the (Name of Vaccine)________ vaccine being administered to (Name of Child)_________ is free from all known and yet unknown zoonotic or human viruses or viral fragments and will not cause acute or chronic illness in the recipient due to viral contamination or as a reaction to the components of this vaccine. (Signature of Physician and Date)_________."
If you do get a signature, hold on to the form.
(Links to model birth plan letter and acceptance of responsibility)
Acceptance of Responsibility. http://www.vaclib.org/legal/accept1.htm
Model Birth Plan Letter for Hospital Births. You can attach an exemption from immunizations. In some states, there are religious exemptions from newborn screening tests such as PKU, etc...
(.doc) Model Letter for Hospital Births (Model11425.doc) Model Birth Plan Letter for Hospital Births. This one is more detailed. You can attach an exemption from immunizations. In some states, there are religious exemptions from newborn screening tests such as PKU, etc...
(.doc)
Model letter for hospital births 2.doc (11426)
Model Birth Plan Letter for Hospital Births for an adopted child...
Model letter for hospital births for adoptions -- Dear Doctor and Medical Staff.doc (11427)
(.doc) VaccineTruth.net/letters/Model letter for hospital births for adoptions.doc
The above documents can also be made available in WordPerfect 
(.wpd) format.
Please email us at Exemptions Contact Page if you want the model birth plan letters in WordPerfect.
Or you can do your own model birth plan letter online...
Hospital Birth Preference Plan ~ Birth Naturally, LLC
http://www.birthnaturally.org/GentleBirth/hospitalplan.htm
The birth plan arrangements and letter should be turned in before delievery date.
This "Refusal to Permit Medical Treatment" form is optional to use.
"Refusal to Permit Medical Treatment" form
Refusal to Permit Medical Treatment. A generic form.
(.pdf) http://www.scpie.com/riskmgmt/forms/refusal_treatment.pdf
AFFIDAVIT is available in Microsoft Word (.doc) and WordPerfect (.wpd) format.
Contact us.
AFFIDAVIT for Georgia Newborn TEXT here...
AFFIDAVIT
I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of the Georgia Republic 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 (Iwe) 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://www.fda.gov/medwatch/SAFETY/2003/03Feb_PI/AquaMEPHYTON_PI.pdf
"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."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, Ga. Code Ann. § 31-12-7, and O.C.G.A. § 20-2-771 (4e) to receive Religious Exemption from Vaccination & testing.
(We are/I am) prepared to sue in Federal Court by invoking 42 USC 1983 if Vitamin K injection, Hepatitis B vaccine, and Newborn Screening is forced upon (our/my) child.
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.
Further Affiant Saith Not
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 Georgia
county of _________________:
On this _______ day of ______________, 200___, 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 ______________________________, 200___
The above AFFIDAVIT is available in Microsoft Word
(.doc) and WordPerfect (.wpd) format.Email us at Exemptions Contact Page
Postnatal - 2 months (first "well baby" visit):
If you do take your new baby to an MD as opposed to a naturopath and/or chiropractor, please be aware and careful of any forms you sign.
We're referring to those "Refusal To Vaccinate" forms put out by the American Academy of Pediatrics. Go to this page below and find out why signing this form is very dangerous. We all know about these forms and how they can be used to undermine parental rights...
http://www.vaclib.org/legal/donotsign.htm
State Form Required: No. However, all exemption waivers must be notarized as required by law.
"By endorsing this particular waiver, parents would essentially be signing an admittance of neglect and or "abuse" for refusing vaccines. The language contained in this waiver could put parents and caregivers in jeopardy down-the-line if they should ever find themselves in the courts due to their child's health problems, when confronted with child protective services, divorce, or just about any matter pertaining to that child that could be used against the parent(s).
Please read any waiver provided by your child's doctor carefully before signing. Instead, offer a formally written and signed letter that simply says that you do not wish to vaccinate your child. If you are unsure of the language in the waiver, buy some time by telling your doctor that you need to consult with a lawyer before signing it. "
Daycare & Preschools:
Download the Microsoft Word document here.
(.doc) VaccineTruth.net/letters/AFFIDAVIT for Georgia Child.docYou may also use the Exemption VacLib-GA.doc below for daycare and preschool.
Schools:
Exemption VacLib-GA.doc
(.doc)
VaccineTruth.net/letters/ExemptionVacLib-Georgia.doc (.wpd)
VaccineTruth.net/letters/ExemptionVacLib-Georgia.wpd Cobb County School District
Form JLC-4
WAIVER OF IMMUNIZATION REQUIREMENTS
DUE TO CONFLICT OF RELIGIOUS BELIEFS
(.doc)
http://www.cobb.k12.ga.us/centraloffice/adminrules/J_Rules/Form%20JLC-4.dochttp://www.mothering.com/discussions/archive/index.php/t-59461.html
http://www.mothering.com/discussions/showthread.php?t=59461
A letter that was used to exempt a child from Hep B vaccine...
Mrs. Jane Doe
123 Any Road
Your City, Georgia. 00000
School _________________________________________
Statement of Religious Objection to Immunization
In accordance with Georgia Immunization program O.C.G.A. § 20-2-771
I hereby certify that the administration of any vaccine and other immunizing agents to my child, ____________, is contrary to our personal Religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempted from the school immunization requirements as set forth O.C.G.A. § 20-2-771(e)
We believe in God, and that God has created us in his image. We are bestowed with His gift, the immune system. I believe it is sacrilegious and a violation of our sacred religious beliefs to violate what God has given us by injected our bodies with vaccines known to cause immune system damage.
We believe that God does not want us to harm our bodies. After much research we believe vaccine to be harmful to the body. They contain toxic ingredients (i.e. Thimerosal, Formaldehyde, Ethylene glycol, Phenol, etc.) that can weaken the immune system and cause illness, lasting damage or death. Many vaccines contain human aborted fetal tissue cells (i.e. Rubella, Chickenpox, Hep A, and some brands of injected polio). This is highly against our beliefs to use any part or benefit from anything doing with the abortion of a human life.
The Hepatitis-B vaccine was designed to protect against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps my parental authority to condemn such activity in my children. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of our faith. With all this, we believe that vaccination is against our personal religious beliefs and wrong in the eyes of God.
Parent __________________________________ Date _______________
Parent __________________________________ Date _______________
Subscribed and Sworn before me this _____ day of ___________, 20____.
________________________________________
Notary's Signature and Seal
O.C.G.A. § 20-2-771(e)
(e) This Code section shall not apply to a child whose parent or legal guardian objects to immunization of the child on the grounds that the immunization conflicts with the religious beliefs of the parent or guardian; however, the immunization may be required in cases when such disease is in epidemic stages. For a child to be exempt from immunization on religious grounds, the parent or guardian must first furnish the responsible official of the school or facility an affidavit in which the parent or guardian swears or affirms that the immunization required conflicts with the religious beliefs of the parent or guardian.
Sample Religious Affidavit found online...
Here is an example of a religious exemption I made up a few months ago. This one uses the Georgia Code as an example. You can find your state's code at:
http://home.san.rr.com/via/STATES/allstates.htm
----------------------------------
An Example Affidavit
-First copy & paste the code from your state. Example follows:
[Education, Part III, Health, Ga. Code Ann. §20-2-771. Rules of Department of Human Resources Public Health, Ga. Comp. R. & Regs.§ 290-5-4-. 01 to .09.]
-Then copy & paste the section that pertains to religious exemption. Example:
[A child may be exempted on religious grounds if a parent furnishes an affidavit swearing that the immunization required conflicts with the religious beliefs of the parent. The immunization may be required in cases when such disease is in epidemic stages. O.C.G.A. § 20-2-771(e). Religious belief in divine healing through faith not to excuse refusal to have children vaccinated. son v. State, 84 Ga. App. 259, 65 S.E. 2d 848 (1951).]
-Then continue with the following:
Pursuant to the aforementioned (insert above code), I, the undersigned, declare the immunization requirements as set forth in O.C.G.A. § 20-2-771(e) contrary to my bona fide religious beliefs and request, as permitted by the law, an exemption from the immunization requirements of your institution for myself or the undersigned minor child under my legal care or guardianship.
NAME ______________________________________
SIGNATURE__________________________________
ADDRESS____________________________________
___________________________________________
PHONE_____________________________________
DATE_______________________________________
___ Check here if declaring exemption for a minor child and enter child's name below.
MINOR CHILD'S NAME _________________________________________
ADDRESS______________________________________
_______________________________________________
PHONE_________________________________________
DATE___________________________________________
----------------------------
**A nice, professional looking affidavit. BTW, they are not allowed to ask your religion.
__________________
**This can be copied to Wordpad & edited to your needs.
Note: Exemption letters, affidavits, and statements must all be notarized in Georgia.
__________________
Cobb County School District
JF-4: Objection to the Use of Social Security Number
(.doc)
JF-4 (English) (.doc)
JF-4 (Chinese) (.doc)
JF-4 (French) (.doc)
JF-4 (Hindu) (.doc)
JF-4 (Korean) (.doc)
JF-4 (Portuguese) (.doc)
JF-4 (Russian) (.doc)
JF-4 (Spanish) (.doc)
JF-4 (Vietnamese) To use the above forms for other schools, simply remove the letterhead to make them generic.
Opt-Outs:
Military Recruiters:
STUDENT OPT OUT FORM regarding the
RELEASE OF NAME, ADDRESS, AND TELEPHONE NUMBER TO MILITARY RECRUITERS
(.pdf) http://www.militaryfreeschools.org/PDF/optout2.pdfUNDERGROUND ACTION ALLIANCE STUDENT OPT OUT FORM
(.pdf) http://www.militaryfreezone.org/opt_out.pdf (.doc) http://veterans4peace.org/opt_out.docSAMPLE ENGLISH - BINGUAL FORMS FOR OPTING OUT
Act to Protect Your Privacy from Military Recruiters
(.pdf) http://www.afsc.org/pacificsw/documents/Opt-Out-Form.pdf STUDENT OPT-OUT - Google Search
STUDENT OPT-OUT NOTICE regarding the instruction of sexuality to children:
STUDENT OPT-OUT NOTICE Valid in all 50 states
(.pdf) http://www.ccv.org/images/StudentOptOutNotice.PDF (.pdf) http://www.catholiccitizens.org/content/img/f26422/opt%20out%20notice.pdf
(.html) http://www.ccv.org/images/StudentOptOutNotice.htm
Entire packet...
(.doc) http://www.mfc.org/respect/Website/Links%20on%20Web%20Page/Opt-Out%20Packet.docSTUDENT OPT-OUT NOTICE - Google Search
Colleges & Universities :
(.doc)
VaccineTruth.net/letters/ImmunizationGeorgia11412.docϑ RELIGIOUS EXEMPTION
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
__________________________________________________________________
Signature of student (required ONLY for religious exemption) Date
Floyd College
3175 Cedartown Hwy., SE, P.O. Box 1864 - Rome, Georgia 30162-1864
CERTIFICATE OF IMMUNIZATION
Bottom of form, page 2.
Part III – Exemptions
I,____________________________________affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
(.pdf) https://www.applyweb.com/apply/floyd/immune.pdfBerry College - 2277 Martha Berry Hwy NW • Mount Berry, GA 30149
Meningitis Vaccination Record/Waiver
(.pdf) http://www.berry.edu/stulife/health/Meningitis.pdf
Check off the Religious Exemption at the bottom of the page of the form. Signature is required.
(.pdf) http://www.berry.edu/stulife/health/ImmunizationRecord.pdfEXEMPTIONS:
______ Exemption on grounds of permanent medical contraindication
______ Exemption on grounds of temporary medical contraindication
______ A. Pregnancy, expected delivery date: _____/_____
______ B. Other, anticipated date of contraindication's end: _____/_____
______ Religious exemption: I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs.
I understand that exemption for any of the reasons listed above subjects me to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
Signature of Student:___________________________________________Date: ____/____/______
GEORGIA PERIMETER COLLEGE
Religious Exemption at the bottom of Page 2
(.pdf) http://www.gpc.edu/~je/pdf_files/Immunization%20Form.pdf Gainsville College (check religious exemption at bottom of form) looks like this...
ϑ RELIGIOUS EXEMPTION
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
Signature of Student (Student signature required only for religious exemption) Date
(.pdf) https://www.applyweb.com/apply/ugsgc/immunization.pdf GEORGIA STATE UNIVERSITY
Georgia State University CERTIFICATE OF IMMUNIZATION (effective Spring Semester 2005)
http://www.gsu.edu/~wwwuhs/newform.htm
Religious exemptions require a notarized statement, preferably from a religious leader. Students 18 years and older cannot submit a statement made by parents or guardian, they muct give their own notarized statement. Students declaring religious exemption will be automatically disenrolled if a case of measles, mumps, or rubella occurs on campus. Disenrollment will continue until the danger of exposure has passed.
Geogia State University
Form Six CERTIFICATE OF IMMUNIZATION 2005 / 2006 Form
PART III – EXEMPTIONS (bottom of Page 2)
Use AFFIDAVIT below, if asked for additional statement.
(.pdf) http://www.applyweb.com/apply/gsurcb/pdf/immunization.pdfCERTIFICATE OF IMMUNIZATION
University System of Georgia
Religious Exemption bottom of page. Only a signature is required.
(.pdf) http://www.applyweb.com/apply/asu/immunization.pdfGEORGIA COLLEGE & STATE UNIVERSITY
CERTIFICATE OF IMMUNIZATION
University System of Georgia Exemption page 2 under PART III - EXEMPTIONS
Only a signature is required.
(.pdf) http://www.gcsu.edu/acad_affairs/enrl_srvcs/admissions/PDF/Certificate_of_Immunization.pdfWill work for ALL of GA colleges unless they have their own form.
COLUMBUS STATE UNIVERSITY
CERTIFICATE OF IMMUNIZATION
(EFFECTIVE SPRING SEMESTER 2005) Only a signature is required.
(.pdf) http://admissions.colstate.edu/pdf_forms/immunization.pdfUniversity of West Georgia
Carrollton, Ga. 30118-4700
(.pdf) http://www.westga.edu/~gradsch/forms/printable/Immunization.pdfOnly a signature is required.
Kennesaw State University
Religious Exemption : I affirm that immunizations are in conflict with my religious beliefs. I understand that I may be subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
Sign at the bottom of page.
Signature (only if declaring religious exemption) ________________________ Date ______________
(.pdf) http://www.kennesaw.edu/col_hhs/hc/immunization.pdfBAINBRIDGE COLLEGE
Sign at the bottom of page.
Religious Exemption Request. I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
Signature of Student __________________________________________________Date:_____________________
required if claiming religious exemption
(.pdf) Bainbridge_College/immunization_form.pdfSouth Georgia College, Douglas, GA 31533
Part III – Exemptions
Bottom of Page 2
(.pdf) http://www.sga.edu/forms/immunization.pdfSavannah State University
Office of Graduate Studies
Savannah, GA 31404
Sign at the bottom of page.
Religious Exemption - I affirm that immunizations required by the University System of Georgia conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
_______________________________________________________________________________
Signature of Student (Student signature required only for religious exemption) Date
(.pdf) http://www.savstate.edu/adm/aa/graduate/forms/Immunization.pdfGordon College - Barnesville, GA
*********************************************************************************************
ϑ Religious Exemption
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
____________________________________________________________________________
Signature of student Date
(Student signature required only for religious exemption)
(.pdf) http://www.gdn.edu/forms/admissions/Immun_form.PDFBoard of Regents of the University System of Georgia
270 Washington Street, S.W., Atlanta, Georgia 30334
Exemption at bottom of page.
(.pdf) http://www.usg.edu/student_affairs/faq/immun/coi-form.pdfGeorgia Southern University
Statesboro, GA 30460-8043
Part III – Religious Exemption - Put checkmark and PRINT name of student, only if claiming religious exemption.
Bottom of Page 2
(.pdf) 2006FEBmedicalhistorycertificateofimmunization.pdfGAINESVILLE STATE COLLEGE
Religious Exemption at bottom of first page.
(.pdf) http://www.gsc.edu/admissions/main/GSC%20Immunization%20Form.pdfArmstrong Atlantic State University
11935 Abercorn Street, Savannah, Georgia 31419
Part III – Exemptions
Bottom of Page 2
(.pdf) http://www.gs.armstrong.edu/gradappforms/Immunization.pdfMercer University
RELIGIOUS EXEMPTION at bottom of form (Must be signed and notarized)
Word Perfect Document (.wpd):
http://www.mercer.edu/chc/atlform.wpd Word Perfect Document (.wpd):
Second Link Some colleges may ask for an additional statement to be attached. For those other colleges and universities, you may use the AFFIDAVIT for Georgia Adult (college & employment religious exemption) below.
This AFFIDAVIT below is sufficient for a religious exemption statement from MMR and any other vaccines to post secondary institutions. Most colleges now have their mandatory waiver for meningitis. The required documentation informs the postsecondary school, and thus the state, that the student has either been vaccinated for meningococcal meningitis or has chosen to decline the vaccine.
This AFFIDAVIT letter will fit nicely on front and back paper.
AFFIDAVIT for Georgia Adult (college & employment religious exemption) ... Edit as needed...
AFFIDAVIT is available in Microsoft Word
(.doc) and WordPerfect (.wpd) format.
Contact us.AFFIDAVIT
I, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being, state Citizen of the Georgia 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, Georgia code, 1-4-13(a) and Georgia code 49-4-183(10)(C) 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.
Further Affiant Saith Not
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 Georgia
county of _________________:
On this _______ day of ______________, 200__, 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 ______________________________, 200___
The above AFFIDAVIT is available in Microsoft Word
(.doc) and WordPerfect (.wpd) format.Click here to Contact Donna.
These Google searches are mostly the college and school exemptions. There are always new forms coming online. Keep a regular check on these to look for newly added forms. Some are for daycare too. The links are the actual keywords that are used.
Immunization Exemption Form
Vaccine Exemption Form
Immunization Waiver
Employment:
(.doc) VaccineTruth.net/letters/Immunization GA employment.docThese forms read like the OSHA Hep B forms, but are covering the MMR/Smallpox Vaccines
Emory University
Measles, Mumps, Rubella (MMR) Vaccine Consent/Declination Form
(.pdf) http://www.ehso.emory.edu/Forms/MMR_Declination_Form.pdf Emory University
Smallpox Vaccine Consent/Declination Form
(.pdf) http://www.ehso.emory.edu/Forms/SmallpoxDeclination.pdf Return To: Immunization Coordinator
Environmental Health and Safety Office
Emory University, School of Medicine
1462 Clifton Road, Suite 300
Atlanta, GA 30322
GEORGIA STATE UNIVERSITY
HEPATITIS B VACCINE DECLINATION
(.pdf) http://www.ovpr.gsu.edu/biosafety/files/GSU%20HBV%20Decline.pdfMost of these are the Hepatitis B vaccine declination forms, such as the OSHA form. There are hundreds of these forms. Rather than linking to each one, here are the Google Search results for these keywords. There are other vaccines that one can decline that are worded like the OSHA forms.
Vaccine Declination Form
or
Hep B vaccine waiver
TB Test:
Mercer University - Required Tuberculin Skin Test - 5TU Mantoux Skin Test (PPD):
None required elsewhere
TB Testing Exemption Letter:
HTML
Sample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBwaiverGen.htm
Microsoft Word Document (.doc)
Sample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBwaiverGen.doc
TB Testing Exemption Letter for Adults:
Microsoft Word Document (.doc)
Sample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBTestingWaiverAdult.doc
WordPerfect Document (.wpd)
Sample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBTestingWaiverAdult.wpd
PDF document (.pdf)
Sample Exemption Letter for TB testing. http://www.vaclib.org/letters/TBTestingWaiverAdult.pdf
Lead Testing Exemption Letter:
HTML
Sample Exemption Letter for Lead testing. May be modified to your use.
http://www.vaclib.org/letters/Lead_testing_waiverGen.htm
Microsoft Word Document (.doc)
Sample Exemption Letter for Lead testing. May be modified to your use.
http://www.vaclib.org/letters/Lead_testing_waiverGen.doc
The above TB and Lead exemption letters courtesy of Deirdre DeVane of Wash DC. Thank you Deirdre!
The adult TB letters were edited by Sherri Tenpenny. Thank you Sherri!
TB Testing Alternatives...
TB can be detected by biofeedback machines that are hooked up to a computer, such as the QXCI, Best BioMeridian MSAS (Meridian Stress Assessment) or Electro Dermal Screening, Quantum Life System, and the F-Scan. You will need to ask specifically for a pathogen scan, especially TB. You will also need to request a printout with the results.
Here are some of the practitioners for Georgia
Georgia BEST™ BioMeridian Practitioners:
Quantum Healing Wellness Center
Dr. Jessica Rand, ND
2810 Peachtree Industrial Blvd. Suite D
Duluth, GA 30097
404-386-5468
http://qhwc.com
E-mail: QHWCDrJess@aol.com
Meridian Stress Assessment
Bio Energetic Stress Assessments & Electrodermal Screening
Immune Function and Pathogen Survey
Scan for signatures of bacteria, viruses, parasites, mold, fungi. Assess the main immune defense systems.
Healing Path, Inc.
Dr. Donna Donache
5025 Chartley Circle, SW, Lilburn, Georgia 30047
770.931.0123 (phone) 770.921-1758 (fax)
http://www.healingpathinc.com/html/naturopathic_assessment.html
http://www.healingpathinc.com
info@healingpathinc.com
IMMUNE FUNCTION/PATHOGEN SURVEY (1 HR.)
Scan signatures of bacteria, viruses, parasites, & fungi. Assess the main immune defense systems: $100
CHRISTIAN HOLISTIC HEALTH CARE
Healthy Touch Whole Health Care
Howard J. Elrod RMT, NCTMB 504 Riverside Parkway, Suite 114
Rome, Georgia 30161
706-232-0708
Georgia QXCI Practitioners:
http://www.theqxci.com/information.php
Elaine Reedy
Visual Cell Biofeedback
1479 Brockett Rd. Suite #102
Tucker, GA 30084
770-270-0355
Peachtree Healing Arts
Lizbeth Widing
Atlanta, GA
678-438-0761
For information on purchase or lease of the new Quantum Life BioFeedback L.I.F.E. System, please email Donna at Exemptions Contact Page and leave your name, mailing address, phone number and email. If you're inquiring for another interested individual or practitioner, please leave their information. The company will then send information and contact the interested parties.
Or you may call 1-888-249-1421.
The L.I.F.E. System is also registered with the FDA for safety issues as a Class 2 Biofeedback Device.
Immunization Registry Opt Out: Forms
(.pdf) Opt-Out of Registry Form
(.pdf)
Formulario para Solicitar la Baja del Registro (Opt-Out of Registry Form en Espanol)
http://health.state.ga.us/programs/grits/publications.asp