INDIANA - IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)
IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)Indiana
Current Statutes & Laws: http://www.909shot.com/state-site/Indiana.htm
Medical & Religious
A school child may not be required to undergo any immunization when the child's parent objects on religious grounds. A religious objection must be:
(1) Made in writing;
(2) Signed by the child's parent; and
(3) Delivered to the child's teacher or to the individual who might order an immunization.
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...
Birth Exemptions:
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.
Religious Exemption from newborn screening allowed.
Ind. Code 16-41-17-2(c)
IC 16-41-17-2
Examinations; religious exemption
Sec. 2. (a) Subject to subsection (c), every infant shall be given examinations at the earliest feasible time for the detection of the following disorders:
(1) Phenylketonuria.
(2) Hypothyroidism.
(3) Hemoglobinopathies, including sickle cell anemia.
(4) Galactosemia.
(5) Maple Syrup urine disease.
(6) Homocystinuria.
(7) Inborn errors of metabolism that result in mental retardation and that are designated by the state department.
(8) Congenital adrenal hyperplasia.
(9) Biotinidase deficiency.
(10) Disorders detected by tandem mass spectrometry or other technologies with the same or greater detection capabilities as tandem mass spectrometry, if the state department determines that the technology is available for use by a designated laboratory under section 7 of this chapter.
(b) Subject to subsection (c), every infant shall be given a physiologic hearing screening examination at the earliest feasible time for the detection of hearing impairments.
(c) If a parent of an infant objects in writing, for reasons pertaining to religious beliefs only, the infant is exempt from the examinations required by this chapter.
As added by P.L.2-1993, SEC.24. Amended by P.L.91-1999, SEC.2; P.L.149-2001, SEC.3.
http://www.in.gov/legislative/ic/code/title16/ar41/ch17.html
[PPT] Indiana Newborn Screening File Format: Microsoft Powerpoint - View as HTML
Selected Screening • Non-invasive Procedure • Refusal Not Allowed ... Indiana’s Universal Newborn Hearing Screening Program is designed to identify infants, ...
www.in.gov/isdh/programs/nbs/ SlideShows/MECONIUMHOSPITALSLIDESHOW.ppt -
Hearing Screening...
In accordance with Ind. Code 16-41-17-2, subsection (c), I certify that the newborn screening to my child, ________________________, is contrary to both ________________________ & my personal religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempt from the newborn screening and examinations of IC 16-41-17-2.
Signature: __________________________________ Date: ________________________
Signature: __________________________________ Date: ________________________
17. What should we do if a family signs the religious waiver just to avoid the screen?
The only accepted reason to waive a screening is due to true religious beliefs and the parents have the right to sign the religious waiver form without question from hospital personnel. When this occurs; however, hospitals are responsible to educate the family on the importance of the hearing screen and assure them of the screening procedure. This will often lead to compliance for the screening if the refusal is not truly due to religious beliefs. If the family still refuses the screening, record the infant in the Reason Codes section of the Monthly Summary Report and send a copy of the signed religious waiver to ISDH with the MSR. IC 16-41-17-2
INDIANA
Statute: Sec. 2. (c) If a parent of an infant objects in writing, for reasons pertaining to religious beliefs only, the infant is exempt from the examinations required by the chapter. [Source: HB 1410, 1999]
Vitamin K Injection...
In accordance with Ind. Statute: Sec. 2. (c) I certify that the hearing screening to my child, ________________________, is contrary to both ________________________ & my personal religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempt from the hearing screening and examinations of Ind. Statute: Sec.2. (b).
Signature: __________________________________ Date: ________________________
Signature: __________________________________ Date: ________________________
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 birth plan letter, 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
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 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
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
It would be good idea to use with the AFFIDAVIT below AND model birth plan letter. I hope someone uses this affidavit, model birth plan letter and refusal form, and that it succeeds. We want to hear about it if someone does succeed with this. The ACCEPTANCE OF RESPONSIBILITY is imperative in exercising your rights for legal exemptions from forced medical experimentation and legalized bioterrorism. DO be prepared to fight for your baby's rights!
Birth plan religious AFFIDAVIT text below. Use with model birth plan letter and/or refusal forms, and edit as needed...
AFFIDAVIT is available in Microsoft Word (.doc) and WordPerfect 
(.wpd) format.
Contact us.
AFFIDAVIT
I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of the Indiana 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 (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://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 and Ind. Code 16-41-17-2(c), Statute: Sec. 2. (c), and Indiana Code # 20-8.1-7-9.5 section 2a 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.
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 Indiana
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___
___________________________________________________________________________
Religious Exemption from newborn screening.
Ind. Code 16-41-17-2(c)
(c) If a parent of an infant objects in writing, for reasons pertaining to religious beliefs only, the infant is exempt from the examinations required by this chapter.
As added by P.L.2-1993, SEC.24. Amended by P.L.91-1999, SEC.2; P.L.149-2001, SEC.3.
http://www.in.gov/legislative/ic/code/title16/ar41/ch17.html
In accordance with Ind. Code 16-41-17-2, subsection (c) I certify that the newborn screening to my child, ________________________, is contrary to both ________________________ & my personal religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempt from the newborn screening and examinations of IC 16-41-17-2.Hearing Screening
Signature: __________________________________ Date: ________________________
Signature: __________________________________ Date: ________________________
Statute: Sec. 2. (c) If a parent of an infant objects in writing, for reasons pertaining to religious beliefs only, the infant is exempt from the examinations required by the chapter. [Source: HB 1410, 1999]
In accordance with Ind. Statute: Sec. 2. (c) I certify that the hearing screening to my child, ________________________, is contrary to both ________________________ & my personal religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempt from the hearing screening and examinations of Ind. Statute: Sec.2. (b).
Signature: __________________________________ Date: ________________________
Signature: __________________________________ Date: ________________________
The above AFFIDAVIT is available in Microsoft Word
(.doc) and WordPerfect (.wpd) format.Click here to Contact Donna.
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. A religious objection must be made in writing, signed & delivered to teacher or individual who ordered immunizations.
"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. "
Anai Rhoads Ford
Human Rights Journalist
Why Signing a Waiver to Avoid Vaccines Can Be Considered Abuse by Anai Rhoads Ford, released 15 November 2005.
http://www.anairhoads.org/
Media Contact (703) 491-1903
Daycare & Preschools:
AFFIDAVIT for Indiana Older Child (daycare or school) below...
AFFIDAVIT is available in Microsoft Word
(.doc) and WordPerfect (.wpd) format.
Contact us.AFFIDAVIT
I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of the Indiana 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/Children). 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 or any of my children’s bodies.
This written statement to exempt (my/our) child from any immunizations, TB testing, and other shots/injections, because (I/we) 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/our) conscientiously held religious beliefs and practices, and violates the free exercise of (my/our) 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/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 abortion. The acceptance of these vaccines promotes abortion and violates the Sixth Commandment of "Thou Shall Not Kill". 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.
(We / I) {First and Last name(s)}, as the {(parent (s) / guardian(s)}of _________________________(name of child) are/am exercising (our/my) rights under the First Amendment of the US Constitution and INDIANA CODE § 20-8.1-7-2 SEC. 2 to receive Religious Exemption from Vaccination.
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 Yahweh 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) 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 Indiana
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.
Indiana: below is posted what one parent did for religious exemption...
The number in Indiana Code is 20-8.1-7-9.5 section 2a for the religious exemption. I [a parent] wrote up & notarized my own using the code #'s saying...
Schools:
In accordance with Indiana Code # 20-8.1-7-9.5 section 2a, I certify that the administration of vaccine & other immunizing agents to my child, ___________________, is contrary to both ___________________ & my personal religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempt from the immunization requirements of the Indiana State Statute 9.5.
Exemption VacLib-Indiana.doc
(.doc) VaccineTruth.net/letters/ExemptionVacLib-Indiana.doc Sample Vaccine Exemption Letter
(.html) http://www.cyberbreezes.com/health/vac-exp-l.htm Opt-Outs:
(Date & Year)
(Your school or board of health address here)
(Attention: person's name?)
(Copies to : person's or organization's names)
Re: Religious Objections to have our children vaccinated: (first child's name, date of birth, school and grade) (second child's name, date of birth...)
Greetings and best wishes!
We are writing to you today to voice our religious opposition to having our children vaccinated with regard to Indiana State Law's which gives exemption on the basis of religious objections.Our religious beliefs include the following:
"We believe in God, and that God has created us in his image. In being created in God's image, we are given his perfect immune system. We are bestowed with His gift, the immune system. We believe it is sacrilegious and a violation of our sacred religious beliefs to violate what God has given us by showing a lack of faith in God. Immunizations are a lack of faith in God and His way, the immune system."
"We believe in Jesus' many promises of protection for us, and that He loves us, and will take care of us if we place our trust in Him. We believe immunizations show no faith in God's promises of protection for us, saying to God that you trust man more than His holy words of protection for us."
"God desires us to love Him and our neighbors first and foremost. This is His first command. By loving Him, we are to fully trust on Him for all things. He is our Lord Father. He is our Rock, our fortress and Savior."
"Our faith is in God and in the Holy Word, being the Holy Bible which is authored by God. This is the instruction book for living that He has left us and in it He tells us He is our protector and we stand firm on His promise. Our faith is in Him!"
"Know ye not that your body is the temple of the Holy Ghost which is in you, which ye have of God and ye are not your own?" (1st Cor. 6:19)
"That your faith should not stand in the wisdom of men, but in the power of God." (1st Cor. 2:5)
"I know with certainty on the authority of Lord Jesus that nothing is unclean in itself: it is only when a man thinks something unclean that it becomes so for him." (Romans 14:14)
"For to His angels he has given command about you, that they guard you in all your ways." (Psalm 91:11)
Thank you for your time and consideration in this important matter.
Very truly yours,
(Your name)
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:
Indiana Under Colleges
DePauw University
Student Health Services
300 East Seminary Street
Greencastle, IN 46135
DePauw University Student Health Services REQUEST FOR EXEMPTION
(.pdf) http://www.depauw.edu/student/health/IMMUNIZATIONWAIVER.pdf AFFIDAVIT for Indiana Adult (college 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 Indiana 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 Indiana 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.
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 Indiana
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:
Most 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:
TB Testing Exemption Letter:
HTMLSample 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:
HTMLSample 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 Indiana
Indiana BEST™ BioMeridian Practitioners:
Natural Rejuvenation, Inc.
Dr. Terri L Hawkins-Fox
6650 West 10th Street, Indianapolis, IN 46214
Tel: (317) 243-3550 Fax: (317) 243-3551
Email: tntconnected@sbcglobal.net
http://www.naturalrejuvenation.com/meridian_stress_assessment.htm
Indiana QXCI Practitioners:
http://www.qxciscio.com/qxci-indiana-in.html
Margaret Rausch, CAT
Certified Athletic Trainer
QXCI Practitioner
Service Areas: Kentucky, Southern Indiana, USA
Specialties: Musculoskeletal injuries, Weight Loss, Chronic Pain
Fees: $100.00 per session; Neuromuscular bodywork, $65 per hour
Contact: Phone:(502) 254-1846 Cell: (502) 777-1833
Kim L. Dexter, CNHP
Certified Biofeedback Specialist
QXCI Practitioner
Service Areas: Elkhart, Mishawaka, South Bend, INDIANA, USA
Specialties: Nutrition, Pain Management, Addictions, Anxiety, Depression, Energy
Fees:
$125 for the first session.
$75 for follow-up sessions are possible.
Pre-payment discounts are also offered.
Contact:
Phone: 574-596-4226 or 574-262-8109
Email: KDexter101@aol.com
Comments: I have had excellent results with chronic pain. 90% of my clients with pain issues are completely pain free after the first few sessions. Most clients leave their therapy session with a renewed sense of vitality and an overall balancing, especially mood and energy issues.,
Richard S. Montieth
QXCI Practitioner
Service Areas: Central Indiana, USA
Specialties: nutrition, pain, emotional stress
Fees:
$75 for initial session (1.5 to 2 hours)
$60 per hour for follow up visits
Contact:
Phone: 317-293-9525
Email: rick@georgetownmarket.com
Comments: My name is Rick Montieth and I am happy to offer QXCI sessions to anyone in the central Indiana area. Please email me with your contact information so that we can arrange an appointment and I can answer any questions you might have.
Heartland Center for Natural Healing
Howard Silvestre, RH (AHG), CBT, CHHP
3801 S. County Rd. 575 East
Selma, IN 47383-9659 USA
Toll Free: 866-798-4978, or locally 765-747-0980
Email: info@heartlandhealing.org
Website: http://www.heartlandhealing.org
Cities Servicing: East-Central Indiana (Indianapolis, Fort Wayne, Anderson, Muncie, Richmond) and Southwest Ohio (Dayton) , USA
Initial Consult $79.00 (2 hours)
Follow-Up Consult $65.00 (1.5 hours)
Regular Therapy session $49.00 (1 hour)
Short Therapy session $30.00 (30 minutes)
Additional Info: : Phone consultations and distant assessment / therapy sessions are also available. Please contact our office for details.
For information on purchase or lease of the new Quantum Life BioFeedback L.I.F.E. System, please email Donna 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:
Immunization Data Exemption
(English) https://chirp.isdh.state.in.us/chirp_files/docs/CHIRP_Data_Exemption.pdf
(Spanish) https://chirp.isdh.state.in.us/chirp_files/docs/CHIRP_Data_Exemption_sp.pdf
Immunization Data Removal
(English) https://chirp.isdh.state.in.us/chirp_files/docs/CHIRP_Data_Removal.pdf
(Spanish) https://chirp.isdh.state.in.us/chirp_files/docs/CHIRP_Data_Removal_sp.pdf
Families for Natural Living Jennifer Zint
6300 Ferstel Rd
Newburgh, Indiana 47630
(812) 858-5037