THIS DOCUMENT MUST BE HANDED TO SCHOOL PRINCIPAL OR SUPERINTENDENT BY PARENT OR GUARDIAN

VACCINATION
EXEMPTION AND RELEASE

Student's Name: (last) __________________________ (first) _________________

(full middle) _________________ (D.O.B.) ____________________

From this date forward, until further notice, we choose not to have our child receive any vaccines, oral or innoculation, due to reason(s) indicated by "X" below. This is confidential medical information not to be transmitted to any person or agency without parent authorization.

_____ Specific vaccines we might choose can not be purchased separately.

_____ The Doctor or Nurse refused to sign affidavit (attached).

_____ We have not been provided with adequate research to show safety, efficacy, and necessity of vaccine.

_____ God's Word, The Holy Bible, indicates vaccines may cause devistating health consequences, not only for the child, but also future generations. See following: I Corinthians 3:16-17, Deuteronomy 14:3 and 24:21, and Leviticus 17:15-17.

___________________________________________________ Print full name of Parent/Guardian (in English please)

____________________________________ Signature of Parent/Guardian	_______________ Date