PENNSYLVANIA - IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)
IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)Pennsylvania
Current Statutes & Laws: http://www.909shot.com/state-site/Pennsylvania.htm
Medical & Religious
The immunization requirements shall not apply in the case of any child whose parent or guardian objects in writing to such immunization on religious grounds.
PDF documents (.pdf)
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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...
§ 28.12. Religious objections.
(a) A health care provider may not collect or cause to be collected, a specimen from a newborn child if the parent or guardian of the newborn child objects on the ground that the specimen collection conflicts with religious beliefs or practices held by the parent or guardian.
(b) If the parent or guardian of the newborn child objects to the collection of the specimen for screening on the ground that the specimen collection conflicts with religious beliefs or practices held by the parent or guardian, the health care provider shall ensure that the recorded objection of the parent or guardian is entered into the medical record of the newborn child. The entry shall include a written statement of the objection signed by the parent or guardian.
http://www.pacode.com/secure/data/028/chapter28/s28.12.html
(.pdf) Entire CHAPTER 28. SCREENING AND FOLLOW-UP FOR DISEASES OFTHE NEWBORN
Eye Prophyalaxis...
§ 27.98. Prophylactic treatment of newborns.
(a) Physicians and midwives attending women in childbirth shall instill in each eye of the newborn child, as soon as practicable after birth, either a 1% silver nitrate solution, or erythromycin ophthalmic ointment or solution as a single application in both conjunctival sacs, or appropriate medication approved by the Department.
(b) If the parent or guardian of the newborn child objects on the ground that the prophylactic treatment conflicts with the parent’s or guardian’s religious beliefs or practices, or if in the opinion of the attending physician treatment is not advisable, prophylactic treatment shall be withheld.
(c) An entry in the child’s hospital record indicating the reason for withholding treatment shall be made and signed by the attending physician and the parent or guardian.
http://www.pacode.com/secure/data/028/chapter27/chap27toc.html#27.98.
§ 501.49. Newborn infant care policies and procedures.
(2) Medication approved by the Department in § 27.98. (relating to prophylactic treatment of newborns), shall be instilled in the eyes of the newborn infant according to statute. If the parent or guardian of the newborn child objects on the ground that the prophylactic treatment conflicts with the parent's religious beliefs or practices, prophylactic treatment will be withheld, and an entry in the child's record indicating the reason for withholding treatment shall be made and signed by the Physician Director of Medical Affairs and the parent or guardian of the newborn infant.
(4) The birth center shall explain to the mother the purpose and nature of the screening tests for diseases of the newborn, required by Chapter 28 (relating to screening and follow-up for diseases of the newborn), give her an informational pamphlet provided by the Department, inform her of her right to refuse the tests because of religious beliefs or practices, and see that the recorded written objection is entered into the medical record of the newborn child and signed by the parent or guardian, if screening is refused.
http://www.pacode.com/secure/data/028/chapter501/s501.49.html
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)."Alternatives to Vitamin K Prophylaxis...
fatalities=death
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.
§ 27.99. Prenatal examination for hepatitis B.
(a) A physician who attends, treats or examines a pregnant woman for conditions relating to pregnancy during the period of gestation or delivery, shall inform the woman that the physician intends to take or cause to be taken, unless the woman objects, a sample of her blood at the time of the first examination (including the initial visit when a pregnancy test is positive) or within 15 days thereafter, but no later than the time of delivery, and shall submit the sample to a clinical laboratory approved by the Department to conduct immunologic testing.
(b) When a pregnant woman tests positive for hepatitis B surface antigen, a physician shall provide the appropriate prophylactic treatment to the newborn within 12 hours after birth. If the parent or guardian of the newborn child objects on the ground that the prophylactic treatment conflicts with the parent’s or guardian’s religious beliefs or practices, prophylactic treatment shall be withheld, and an entry in the child’s hospital record indicating the reason for withholding treatment shall be made and signed by the attending physician and the parent or guardian.
http://www.pacode.com/secure/data/028/chapter27/chap27toc.html#27.99.
§ 23.84. Exemption from immunization. [28 PA. CODE CH.23]
(b) Religious exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.
(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...
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 (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 contact us 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
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 forms, and succeeds. We want to hear about it when someone is successful 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 available in Microsoft Word (.doc) and WordPerfect (.wpd) format.
AFFIDAVIT
I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of the Pennsylvania 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 US Constitution, PA. CODE § 23.84, PA. CODE § 28.12(b) and PA. CODE §27.98(b) to receive Religious Exemption from Vaccination, ALL injections, prophylaxis, & 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 Pennsylvania
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___
_____________________________________________________________
§ 23.84. Exemption from immunization. [28 PA. CODE CH.23]
(a) Medical exemption. Children need not be immunized if a physician or the physician's designee provides a written statement that immunization may be detrimental to the health of the child. When the physician determines that immunization is no longer detrimental to the health of the child, the child shall be immunized according to this subchapter.
(b) Religious exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.
§ 28.12. Religious objections. [28 PA. CODE CH.28]
(a) A health care provider may not collect or cause to be collected, a specimen from a newborn child if the parent or guardian of the newborn child objects on the ground that the specimen collection conflicts with religious beliefs or practices held by the parent or guardian.
(b) If the parent or guardian of the newborn child objects to the collection of the specimen for screening on the ground that the specimen collection conflicts with religious beliefs or practices held by the parent or guardian, the health care provider shall ensure that the recorded objection of the parent or guardian is entered into the medical record of the newborn child. The entry shall include a written statement of the objection signed by the parent or guardian.
Above AFFIDAVIT now available in both Microsoft Word
(.doc) and WordPerfect (.wpd) format.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, just a written statement from parent.
"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:
§ 23.45. Objections to examination on religious grounds.
(a) School children or school employes may be excused from regular or special medical or dental examinations on presentation of written evidence to the school administrator that the examinations are contrary to the religious beliefs of the parent or guardian of the child or of the employee.
(b) Exemption from medical or dental examinations will not be granted if the Department of Health finds that facts exist under which the exemption constitutes a present substantial menace to the health of other persons exposed to contact with the unexamined person.
§ 23.84. Exemption from immunization. [28 PA. CODE CH.23]
(b) Religious exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.
Use one of the exemption letters under schools below...
Schools:
§ 23.45. Objections to examination on religious grounds.
(a) School children or school employes may be excused from regular or special medical or dental examinations on presentation of written evidence to the school administrator that the examinations are contrary to the religious beliefs of the parent or guardian of the child or of the employee.
(b) Exemption from medical or dental examinations will not be granted if the Department of Health finds that facts exist under which the exemption constitutes a present substantial menace to the health of other persons exposed to contact with the unexamined person.
§ 23.84. Exemption from immunization. [28 PA. CODE CH.23]
(b) Religious exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.
Public schools:
There are several to choose from...
PA Hepatitis B vaccine exemption letter.
(.doc) VaccineTruth.net/letters/PennsylvaniaHebB10985.doc PA Religious Exemption Letter for all vaccines.
(.doc) VaccineTruth.net/letters/Pennsylvania10986.doc Statement Of Religious Objection To Immunization in Pennsylvania.doc (with scriptures).
(.doc)
VaccineTruth.net/letters/PennsylvaniaStatement10987.doc
WEST SHORE SCHOOL DISTRICT
VARICELLA (chicken pox) IMMUNIZATION PERMISSION/REFUSAL FORM
(.pdf)
http://staff.wssd.k12.pa.us/rabelson/VaricellaPerm.PDFHEPATITIS B/MMR IMMUNIZATION PERMISSION/REFUSAL FORM
MMR II IMMUNIZATION PERMISSION/REFUSAL FORM
(.pdf)
http://staff.wssd.k12.pa.us/rabelson/HepBMMRParPerm.PDFNote: These are only refusal forms, you will still need to use one of the exemptions above.
An old Pennsylvania Exemption Form...
http://www.unhinderedliving.com/Vaccine.jpg
Here is a sample form that can be used from http://www.marysherbs.com/Miscellaneous/v-e-formP.htm
|
Exemption to Immunization |
| Name ________________________________________ Birthdate ________________________
Address ______________________________________ Parent/Guardian ____________________ _____________________________________________ Telephone _______________________ Please Circle Present Grade: K 1 2 3 4 5 6 7 8 9 10 11 12 Sp. Ed. |
|
STATEMENT OF EXEMPTION TO IMMUNIZATION LAW |
|
MEDICAL EXEMPTION The physical condition of the above named child is such that immunization would endanger life or health. Signed _________________________________________________ Date __________________ (Physician) |
|
RELIGIOUS EXEMPTION (Includes a strong moral or ethical conviction similar to a religious belief.) Parent or guardian of the above named child adheres to a religious belief whose teachings are opposed to such immunizations. State your reason for requesting a religious exemption _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signed __________________________________________________ Date _________________ (Parent or Guardian) |
Homeschools:
A Medical Exemption Form
(.doc)
http://www.geocities.com/hardingpj/medicalexemptionform.doc Medical, dental and Immunization Exemptions for home school...
Microsoft Word:
(.doc)
http://www.geocities.com/hardingpj/medicalexemptionform.docPDF:
(.pdf) http://www.geocities.com/hardingpj/medicalexemptionform.pdf The following is a version of the medical exemption form one can file with their affidavit instead of filing other more specific medical forms. The version below is from The Pennsylvania Home Education Handbook by Diana Baseman, with permission from the author.
Available here in 3 file formats for offline reading or printing. Everyone should be able to view at least one of them.
Rich Text Format:
(.rtf)
http://www.phen.org/medexemp.rtf Microsoft Word:
(.doc)
http://www.phen.org/medexemp.doc PDF:
(.pdf)
http://www.phen.org/medexemp.pdf PHEN- home education affidavit... http://www.phen.org/affidavit.html
Available here in 3 file formats for offline reading or printing. Everyone should be able to view at least one of them.
affidavit in .pdf (Adobe Acrobat) format.
(.pdf)
http://www.phen.org/affidavit.pdf affidavit in .doc (Word for Windows) format.
(.doc) http://www.phen.org/affidavit.doc affidavit in .rtf (rich text) format.
(.rtf) http://www.phen.org/affidavit.rtf Your notarized affidavit should include an outline of proposed education objectives by subject area and be accompanied by your medical papers or exemption. Objectives... http://www.phen.org/objectives.html
Pennsylvania Home Education Network: http://www.phen.org/
This is a sample medical exemption form that you may submit to the state.
http://www.mdhsa.pa.net/PA%20Medical%20Exemption.htm
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:
Widener University...
Religious Exemption
If you are requesting an exemption from fulfilling the university required vaccines based upon religious reasons, you must provide a letter from your church, which states that it is the belief (or doctrine) of that church to recommend against medical vaccinations, and that you are an active member of the church in good standing. The designated religious leader of your church must write the letter on your place of worship's letterhead, which should include his/her address and telephone number.
You must also complete a Religious Exemption Form, which will be sent to a student upon request. Call Student Health Services Department at 610-499-1183.
Rev. 5/02
See AFFIDAVIT and good religious reasons below...
Good religious reasons...
These constitute good reasons when a school or college asks for your religious reason on a form that says, state your reason here, attach rationale, or state why a particular vaccination is contrary to your religious beliefs, etc...
Often you will be requested to state your rationale for your vaccination exemption petition. What follows is what is used for public schools, parochial schools, private colleges, and public universities.
Q: What constitutes a religious conflict with vaccination?
A: All vaccines are made in violation of God’s Word. Vaccines are made with toxic chemicals that are injected into the bloodstream by vaccination. All vaccines are made with foreign proteins (viruses and bacteria), and some vaccines are made with genetically engineered viral and bacterial materials.
A conflict arises if you believe that man is made in God’s image and the injection of toxic chemicals and foreign proteins into the bloodstream is a violation of God’s directive to keep the body/temple holy and free from impurities.
Vaccines are produced in animal tissues. A conflict arises if you accept God’s warning not to mix the blood of man with the blood of animals. Some vaccines are produced in aborted fetal tissue.
A conflict arises if your 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. When it is believed that the practice of abortion should not be encouraged or supported in any manner, a conflict may arise with vaccines produced in aborted fetal tissue even though you didn’t have anything to do with the abortions from which the vaccines are made from.
The Hepatitis-A vaccine containing MRC-5 is obtained from human babies that were electively aborted. WI-38 was created from the tissue of an aborted fetus and is used for the rubella portion of the MMR-II vaccine. RA 273 was created from the tissue of an aborted fetus, and is used for MMR-II vaccine. 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 this/these vaccine(s) promotes/promote abortion and violates the Sixth Commandment of "Thou Shall Not Kill".
The Chickenpox (Varivax) vaccine containing MRC-5 and RA 273, is obtained from human babies that were electively aborted. The acceptance of this vaccine 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.
For a child under age 18, where parent has to make the statement, concerning Hep B vaccine...
The Hepatitis-B vaccine protects 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 child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of our faith.
”I believe that inherent in each individual is an innate intelligence, provided by God, which will protect the host environment and provide homeostasis.” “Life and physical health are precious gifts entrusted to us by God. We must take reasonable care of them…” [2288 – Catechism of the Catholic Church 1994]
“The virtue of temperance disposes us to avoid every kind of excess: the abuse of … medicine.” [2290 – Catechism of the Catholic Church 1994]
(Indicate rationale and attach statement from clergy or other authority.)
You do not need to belong to a church or religious organization to claim religious exemption from vaccines.
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.
AFFIDAVIT for Pennsylvania 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 Pennsylvania 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 Pennsylvania 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 Pennsylvania
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___
DeSales University
2755 Station Avenue
Center Valley, PA 18034
(610) 282-1100
DeSales University Meningitis Vaccine Waiver Form
(.pdf)
http://www.desales.edu/assets/desales/MeningitisWaiver.pdfSeton Hill University | One Seton Hill Drive | Greensburg, PA | 15601
Statement of Exception to College and University Student Vaccination Act
(.pdf) http://www.setonhill.edu/forms/wc_exemption_form1.pdf University of Pennsylvania Immunization Requirements and Exemptions.
http://www.vpul.upenn.edu/shs/imreq05c.html
Student Health Services
Gannon University
109 University Square
Erie, PA 16541-0001
MANDATORY UNIVERSITY MENINGITIS VACCINE/EXEMPTION FORM
(.doc) http://www.gannon.edu/depts/healthctr/MENINGITIS%20move%20in%20form.docPenn State University:
Penn State University Meningococcal Waivers:
From this page... http://www.hfs.psu.edu/vaccine/forms.htm
The Exemptions are in Section D of the forms. Looks like this...
Penn State University Meningococcal Waiver (Altoona)
(.pdf)
http://www.hfs.psu.edu/vaccine/forms/altoona.pdfPenn State University Meningococcal Waiver (Beaver)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/beaver.pdfPenn State University Meningococcal Waiver (Berks)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/berks.pdfPenn State University Meningococcal Waiver (Erie, The Behrend College)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/erie.pdfPenn State University Meningococcal Waiver (Harrisburg)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/harrisburg.pdfPenn State University Meningococcal Waiver (Hazleton)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/hazleton.pdfPenn State University Meningococcal Waiver (McKeesport)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/mckeesport.pdfPenn State University Meningococcal Waiver (Mont Alto)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/montalto.pdfPenn State University Meningococcal Waiver (University Park)
(.pdf) http://www.hfs.psu.edu/vaccine/forms/universitypark.pdfPenn State University Meningococcal Waiver (The Milton S. Hershey Medical Center, The College of Medicine)
(.pdf)
http://www.hfs.psu.edu/vaccine/forms/hershey.pdf Penn State University - other vaccines. (d) Individuals requesting exemptions for medical or religious reasons will need approval by the Director of University Health Services. No downloadable exemption forms available for other vaccines. You'll have to write your exemption for the other vaccines.
Thomas Jefferson University
University Health Services
Philadelphia, PA 19107
STATEMENT OF EXEMPTION TO COLLEGE AND UNIVERSITY STUDENT VACCINATION ACT
Meningococcal Exemption Form (66K)
(.pdf) http://www.jefferson.edu/uhs/documents/Exemption.pdf 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:
Saint Francis University, Loretto, PA 15940
DEPARTMENT OF PHYSICIAN ASSISTANT SCIENCES
HEPATITIS VACCINE REFUSAL FORM
(.pdf) http://www.francis.edu/PhysAsst/pdffiles/hepvcref.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: required for school.
§ 23.9. Tuberculosis tests.
§ 23.9. Tuberculosis tests.
(a) Pupils to be tested. A test for tuberculosis shall be administered upon original entry into school, and in grade nine by a tuberculin test.
(b) Testing methods. The tuberculin test may be administered by either the multiple puncture method or by the Mantoux test using intermediate strength tuberculin (PPD 0.0001 mg.).
(c) All tuberculin reactors. Tuberculin reactors shall be X-rayed. Chest X-rays of tuberculin reactors may be provided by local public or private health agencies. Arrangements for the examinations are the responsibility of the local school authorities.
(d) Tuberculin testing programs. A school board or joint school board which finds that individual schools within the school district or jointure have significant differences in the reactor rate may implement tuberculin testing programs for individual schools in accordance with the following:
(1) A test for tuberculosis shall be done annually on original entry into school and in the ninth grade by a tuberculin test in schools with a prior tuberculin reactor rate of 0.5% or above in these grades.
(2) A test for tuberculosis shall be done every third year upon original entry into school and in the ninth grade by a tuberculin test in those schools with a tuberculin reactor rate below 0.5% in these grades. A school which subsequently shows an increase to a level above 0.5% shall renew the annual testing program until the reactor rate descends below 0.5% again.
Source The provisions of this § 23.9 amended July 22, 1971, effective July 23, 1971, 1 Pa.B. 2163.
Cross References This section cited in 28 Pa. Code § 23.21 (relating to general).
No part of the information on this site may be reproduced for profit or sold for profit.
This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
Yes, for Widener University. No exemption.
Only targeted TB testing for University of Pennsylvania. http://www.vpul.upenn.edu/shs/tb.html
Haverford College (Mandatory TB testing)
Thomas Jefferson University (Mandatory TB testing)
http://www.jefferson.edu/uhs/incoming.cfm?version=print
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 request a printout with the results.
Here are some of the practitioners for Pennsylvania
Pennsylvania BEST™ BioMeridian Practitioners:
Please call contact below to find BioMeridian practitioners in your area or closeby.
Oksana Gorodetsky
Marketing/Administrative Coordinator
BioMeridian International
12411 South 265 West, Suite F
Draper, UT 84020
T 801-501-7517
F 801-501-7518
Toll Free 888-224-2337
ogorodetsky@biomeridian.com
Pennsylvania QXCI Practitioners:
The Herb Barn
Stan Doublosky
Specializes with herbal medicinal herbs, ph testing, cleansing, detox, and dietary coaching
Nazareth, Pa 18604
610-746-9969
theherbbarn@rcn.com
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.
WHOLEFOOD
FARMACY
Debbie Grater, director
651 N. Price Street
Pottstown, PA 19464
(610) 326-2032 (Debra Grater)
Email: debbiehaven@msn.com
* Pennsylvania Immunizations Laws, school requirements, exemptions,...
* Shaken Baby Syndrome: Does it really exist?
or Contact Brigette who works together with Debbie
Brigitte Koren
Easton, Pa. 610-438-5171
E-mail: Brigitte Koren brigittekoren@hotmail.com