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Thursday, March 23, 2017

New Exemption Forms for Various States

Every now and then, I'll go on a search spree, and find updated and/or new exemption forms online.

These are to share with Vac Lib to put on the exemption pages there, and also to share with Kenny Valenzuela for his exemption pages at Experimental Vaccines site.

So as I find them, going to start sharing here as well.  Only getting the NON incriminating ones.

Share these widely, and even better yet, DOWNLOAD them to your computers, in case they disappear.  Sometimes links change, forms are pulled offline, etc..

EDITED:  Added South Carolina, Georgia, and Montana, and replaced TWO links from CO, which had changed since this post.  Beware of that, it happens, as previously warned.






Oklahoma:

For the longest time, Oklahoma always had this crappy scanned pdf online form from various sites and we have always wanted a good original one.  Well, I finally found the original that the state had finally put up on their website.

[PDF] certificate of exemption - State of Oklahoma
https://www.ok.gov/health2/documents/IMM_School_ODH_216a_Certificate_of_Exemption.pdf

[PDF] certificate of exemption - Epic Charter Schools
http://epiccharterschools.org/document/immunization-exemption

I also have current updated links for Maine and Delaware...  I've been making groups for each state and adding the non incriminating files in the files section of each state's group.  Just added more forms states and links.


Delaware:

http://delcode.delaware.gov/title14/c001/sc02/index.shtml#P227_51758
http://vaccines.procon.org/sourcefiles/delaware_vaccine_law.pdf

Exemptions:  Statute 14: 131 (no date available) allows exemption from immunization requirements under the following circumstances: (1) Presentation of a written statement from a physician, i.e., medical doctor or doctor of osteopathy, stating that the student should not receive the prescribed immunizations because of the reasonable certainty of a reaction detrimental to that person (history of clinical illness of measles or rubella not acceptable as cause for exemption), or (2) Presentation of a notarized Affidavit of Religious Belief (outlined in statute) that states that the parents or legal guardians of the student reject the concept of immunization because of individual religious beliefs.  In the case of a vaccine preventable epidemic, any child enrolled in school who is exempt from the immunization program shall be temporarily excused from attendance at public school.

AFFIDAVIT OF RELIGIOUS BELIEF
STATE OF DELAWARE

[PDF] affidavit of religious belief - State of Delaware
http://www.dhss.delaware.gov/dph/hsp/files/olpprelexempt.pdf

[PDF] Notarized Affidavit of Religious Belief
http://www.doe.k12.de.us/cms/lib09/DE01922744/Centricity/Domain/150/Immunization%20-%20Notarized%20Affidavit%20of%20Religious%20Belief.pdf

[PDF] Affidavit for Religious Exemption from Vaccination Requirement
https://www.wmsde.org/Customized/Uploads/ByDate/2016/April_2016/April_8th_2016/Vaccination%20affidavit%208-201541984.pdf

[PDF] Affidavit for Religious Exemption from Lead Testing Requirement
https://www.wmsde.org/Customized/Uploads/ByDate/2015/January_2015/January_26th_2015/lead%20exemption30149.pdf

[PDF] Delaware Religious Belief Affidavit Vaccine Exemption Form
http://experimentalvaccines.org/wp-content/uploads/2013/05/Delaware-Religious-Belief-Affidavit-Vaccine-Exemption-Form.pdf

[PDF] Immunization - School Vaccination Medical Exemption Form
http://www.doe.k12.de.us/cms/lib09/DE01922744/Centricity/Domain/150/Immunization%20-%20School%20Vaccination%20Medical%20Exemption%20Form.pdf

[PDF] University of Delaware Immunization and History Form
http://www.brandywinepediatrics.com/admin/uploads/UDImmunizationInformationFormpdf.pdf


Maine:

Maine Religious and Philosophical Belief Exemption Form
IMMUNIZATION EXEMPTION FORM
http://experimentalvaccines.org/wp-content/uploads/2013/06/Maine-Religious-and-Philosophical-Belief-Exemption-Form.pdf


Maine Regional School Unit 21
Arundel, Kennebunk, Kennebunkport , Maine
Immunization Exemption Form
http://experimentalvaccines.org/wp-content/uploads/2013/06/Maine-Regional-School-Unit-21-Immunization-Exemption-Form.pdf


RSU No. 5
Durham – Freeport - Pownal
Maine Immunization Exemption
http://www.rsu5.org/userfiles/-4/my%20files/exemption%20formfinal.pdf?id=173


MSAD 49
Fairfield - Albion - Benton - Clinton
District Medical Immunization Exemption Form
MEDICAL IMMUNIZATION EXEMPTION FORM
http://www.msad49.org/UserFiles/Servers/Server_3012026/Image/Health%20Services/District%20Medical%20Immunization%20Exemption%20Form.pdf

MSAD 49
Fairfield - Albion - Benton - Clinton
District Medical Philosophical and Religious Immunization Exemption Form
PHILOSOPHICAL/RELIGIOUS IMMUNIZATION EXEMPTION FORM
http://www.msad49.org/health_services/immunizations/district_medical_philosophical_and_religious_immunization_exemption_form/


SCARBOROUGH SCHOOL DEPARTMENT
P. O. BOX 370
SCARBORUGH, ME 04074
IMMUNIZATION EXEMPTION FORM
An annual signed exemption due to religious or philosophical reasons
Exemption Form [PDF]
https://db0aae9c-a-471900dc-s-sites.googlegroups.com/a/scarboroughschools.org/sps/central-office/health-services/health-forms/Immunization-Exemption-Form.pdf?attachauth=ANoY7crIVbKlJIQZ2MdbSEhLszPLGdbyCZKAbwGhrjEa4JO1NDmD7o1at2KbP0BWL3IpDiTV77UgY44fLlL8IdJXagsZCh37BJGg1jn0yyqyjR4pvH3HAmo0xpgv_SS0RVQ_XZRbQ6kC7PkZEE1yccyJCYLTHOKccnZbJP3aKwS9v813K8QYuJj0qdrYFcwd64uFv9AQ2PbBf7N3yBUhDdHe3mWo_CrWL3Q3Q06tez2Cl0yriwTSJZKGLOxXnAQBAho3V041jfB8rrYa4cXi4-JK5x8UX22uCbOk_F6XtJN4_VkCwtCS_Mk%3D&attredirects=0


University of Southern Maine
If you have not been vaccinated and therefore can not provide proof of immunizations due to moral, political or religious beliefs.
In this case, you may download our "Objection Letter" and submit that in place of the records.
https://usm.maine.edu/sites/default/files/University%20Health%20and%20Counseling%20Services/Objection%20letter.pdf


University of Maine at Augusta Vaccine Waiver Form
http://experimentalvaccines.org/wp-content/uploads/2013/06/University-of-Maine-at-Augusta-Vaccine-Waiver-Form.pdf


[DOC] My SMCC - Southern Maine Community College
*WAIVER SECTION* Page 2
https://my.smccme.edu/ICS/icsfs/Immunization_Verification_Waiver_2015.doc?target=306d0fd3-d80d-4d01-9304-1fb503e3ae2e

[PDF] Immunization Waiver Form - University of Maine at Augusta
http://uma.edu/assets/docs/registrar/immunizationwaiver.pdf


Colorado:

Immunization Non-Medical Exemption Form (Religious and Personal Belief)
https://www.colorado.gov/pacific/sites/default/files/Imm2_Non-Medical%20Exemption-English-0417.pdf

Immunization Medical Exemption Form
https://www.colorado.gov/pacific/sites/default/files/Imm_Medical-Exemption-English-0417.pdf

Other Languages Here:
https://www.colorado.gov/pacific/cdphe/vaccine-exemptions


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South Carolina:


South Carolina Certificate of Religious Exemption (From Immunization)
Religious Exemption form (DHEC form 1126)

http://www.vaclib.org/letters/DHEC-1126.pdf
http://experimentalvaccines.org/wp-content/uploads/2013/06/South-Carolina-Certificate-of-Religious-Immunization-Exemption.pdf
http://www.nvic.org/Vaccine-Laws/state-vaccine-requirements/northcarolina/south-carolina-religious-waiver.aspx


[The medical exemption] form is at the bottom of the DHEC 1148

http://www.vaclib.org/letters/DHEC-1148.PDF
http://experimentalvaccines.org/wp-content/uploads/2013/06/South-Carolina-Medical-Vaccine-Immunization-Exemption-Form.pdf


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Georgia:

VACCINATION EXEMPTION PURSUANT TO THE
OFFICIAL CODE OF GEORGIA ANNOTATED § 20-2-771
4. (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.

ALL GA Vaccine Exemption Affidavits and forms MUST be notarized.

GA Affidavit of Religious Exemption
https://wellness-chiropractic-center.com/misc/vacaffidavit.pdf?fref=gc
* Best form, works for any school.

]DOC] Form JGC-4 - Cobb County School District
http://www.cobbk12.org/centraloffice/adminrules/J/Form_JGC-4.docx

Atlanta Public Schools:
IMMUNIZATION REQUIREMENTS:
AFFIDAVIT OF RELIGIOUS OBJECTION
https://www.atlantapublicschools.us/cms/lib/GA01000924/Centricity/Domain/74/Religious%20Objection%20Affidavit%20-%20Immunizationsv2.pdf

ExemptionVacLib-Georgia.137130643.pdf
http://www.basicchiropractic.com/yahoo_site_admin/assets/docs/ExemptionVacLib-Georgia.137130643.pdf

AFFIDAVIT OF RELIGIOUS OBJECTION TO IMMUNIZATION
https://dph.georgia.gov/sites/dph.georgia.gov/files/DPH%20Form%202208%20Religious%20Objection%20to%20Immunization%20(FINAL).pdf

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Montana:

[PDF] Religious Exemption Form - Dphhs
AFFIDAVIT OF EXEMPTION ON RELIGIOUS GROUNDS FROM MONTANA SCHOOL IMMUNIZATION LAW AND RULES
https://dphhs.mt.gov/Portals/85/publichealth/documents/Immunization/School/ReligiousExemptionForm2015.pdf

BEST Medical Exemption Form because it reads the law on ME's:
HES101_2013 MT Medical Exemption Form.pdf
On Page 2 (SECTION IV EXEMPTIONS)
1. Medical: TO BE SIGNED BY A PHYSICIAN (See Section III, Health Department or Physician)
http://experimentalvaccines.org/wp-content/uploads/2013/06/Montana-Medical-Vaccine-Exemption-Form-HES-101.pdf

[PDF] Medical Exemption Form - Dphhs
Medical Exemption Statement
https://dphhs.mt.gov/Portals/85/publichealth/documents/Immunization/2015/HES101AMedicalExemptionForm2015.pdf


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Arizona:

Beware of the language of this current form...

This...

I have been informed that by not receiving this vaccine, my child is at increased risk of developing diphtheria if exposed to this disease . Serious symptoms and effects of this disease include: heart failure, paralysis (can’t move parts of the body), breathing problems, coma, and death

can be edited to this by Crossing out the "not" and change the word "disease" to "vaccine" to read like this...

I have been informed that by receiving this vaccine, my child is at increased risk of developing diphtheria if exposed to this vaccine . Serious symptoms and effects of this vaccine include: heart failure, paralysis (can’t move parts of the body), breathing problems, coma, and death

Because the actual vaccine itself CAN and often DOES CAUSE the so-called risks of the disease, and that is proven by the Tripedia package insert. If the schools give a hard time, then attach a printed copy of the PDF Tripedia Package insert which states these adverse reactions and events.

Same editing applies to the Spanish form, as well.

New Incriminating Forms:

Arizona-Department-Health-Services-Waiver.pdf
http://tempeprep.org/wp-content/uploads/2014/12/Arizona-Department-Health-Services-Waiver.pdf

Formulario de Exención por Creencias Religiosas.pef
http://azdhs.gov/documents/preparedness/epidemiology-disease-control/immunization/school-childcare/religious-belief-exemption-espanol.pdf

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Older NON-incrimating Forms:

From the older VacLib archived pages:
https://web.archive.org/web/20090211000957/http://vaccinetruth.net/exempt/arizona.htm

Here is the list of the older NON incriminating Arizona forms. Parents can try these instead, but it may depend on the school, whether they will accept the older forms. So please try them, and also download to share with others too.

Daycare & Preschools:

REQUEST FOR EXEMPTION TO IMMUNIZATION CHILD CARE FACILITIES (English and Spanish)
 (.pdf) http://www.azdhs.gov/als/forms/ccgh10.pdf 

Schools: 

Request for Exemption to Immunization Schools (English and Spanish)
 (.pdf) http://azdhs.gov/phs/immun/pdf/school-exemption-form.pdf 

Request for Exemption to Immunization - School (Spanish)

Sequoia Choice - AZ Distance Learning - Mesa, AZ. 85211-1405
 (.pdf) http://scazdl.org/new/forms/waiver.pdf

ExemptionVacLib-Arizona.doc
 (.doc) VaccineTruth.net/letters/ExemptionVacLib-Arizona.doc

If all else fails, and a parent is forced to sign an incriminating form, then write or sign name "Under Duress".

https://consciousawarenessforall.wordpress.com/2015/02/12/duress/

https://www.linkedin.com/pulse/how-sign-your-name-without-assuming-liability-cathy-bilsky


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