DECLARATION OF VACCINATION EXEMPTION
“EXEMPTION FROM IMMUNIZATION”, I hereby deare that I as guardian/parent/adult having responsibility for my self/child named herein ( )
withhd my consent and let it be known that said adult/minor is exempted from any and all vaccinations on the grounds that such is contrary to my personal beliefs.
IMMUNIZATIONS OF A PERSON SHALL NOT BE REQUIRED FOR EMPLOYMENT, ADMISSION TO SCHOOL OR OTHER INSTITUTIONS.. IF THE GUARDIAN, PARENT, OR ADULT WHO HAS ASSUMED RESPONSIBILITY FOR HIS OR HER CUSTODY AND CARE IN THE CASE OF A MINOR, THE PERSON MUST FILE WITH THE GOVERNMENT AUTHORITY, A LETTER OR AFFIDAVIT STATING THAT SUCH VACCINATIONS IS CONTRARY TO HIS/HER BELIEFS…
Any institution, school or medical authority which tries to enforce vaccination on children or anyone else is in violation of laws of the United States, and may be subject to prosecution.
Amendment 14 of the United States Constitution: “No state shall make or impose any law which shall abridge the privileges or immunities of the citizens of the United States, nor shall any state deprive any person of life, liberty, or property.”
Amendment 4 of the United States Constitution:
“The right of the people to be secure in their persons shall not be violated.”
INTERNATIONAL VACCINATION EXEMPTION
Exemption has been ratified and approved by all United Nation members under WORLD HEALTH ORGANIZATION International Sanitary Regulations Article 83, chapter IV; “each individual has the right of vaccination exemption.”
SUBSCRIBED AND AFFIRMED TO BEFORE ME ON THIS ( ) DAY OF ( ), 20( ).
SIGNATURE AND DATE
NOTARY PUBLIC COMMISION EXPIRES
Tommie Forster #1403251
Nottoway Correctional Center
P.O. Box 488
Burkeville, VA 23922