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Vaccination Liberation Information

California
State Exemption Page
VacLib.org & VaccineTruth.net Exemption Page


Statutes/L A W S
Link to state law.
National Vaccine Information Center:
NVIC link to state law.


Alert: California Vaccine Exemptions
California AB2109 has been signed into law and takes effect January 1, 2014.
At that time, parents must pay for a Dr. Appointment to TRY to Obtain a Personal Belief Exemption
Language of the changed law:
http://www.leginfo.ca.gov/pub/11-12/bill/asm/ab_2101-2150/ab_2109_bill_20120831_enrolled.pdf


Additional note: California Governor Edmund Brown has directed the Health Department to implement a separate Religious Exemption that will not require a health care signature. Time will tell if this "direction" will be honored.

M O R E on California Law
Calif Code snips    |    Summary/List of commonly used links


For additional help with exemptions, birth plan, etc questions:
Check our Vaccination Liberation State Chapter and other resource organizations page for help in your state.

If your state specific help is not available, Contact us.


- - - Available Exemptions - - -
Medical  &  Personal Beliefs Exemption (PBE)
  Note: In California, the religious, philosophical and "other" belief exemptions are all under the umbrella term: "Personal Beliefs Exemption" (PBE).


Important:
July 1, 2011 a new Tdap booster vaccine is required to enter California schools, grades 7-12. Both the medical and Personal Beliefs Exemption (PBE) are available. Schools have been given a new form, CDPH 8261 to be used for the Tdap booster. Click here for our FAQ on CDPH 8261.



Your Choice.
Join thousands of other pioneers in refuting the presumed authority the corporate government has over your life.
Break the presumptions by negating adhesion contracts. Find out if your state's corporate statutes actually apply to you. Did you sign a contract binding you to adhere to their statutes? Not likely. To learn more, go to this page.

PDF documents (.pdf)

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Related Pages


State Resource Individuals

Finding Non_Vaccinating_Physicians

CA law snips - Quicklinks
EDUCATIONAL AND CHILD CARE FACILITY IMMUNIZATION REQUIREMENTS ... 120325-120380
120325.
   (c) Exemptions from immunization for medical reasons or because of personal beliefs.

TUBERCULOSIS TESTS FOR PUPILS ... 121475-121520
HEALTH AND SAFETY CODE SECTION 121475
   (c) Exemptions from tuberculosis tests because of personal beliefs.

HEALTH AND SAFETY CODE SECTION 121505. The certificate shall not be required for a person who is subject to an order made pursuant to subdivision (a) of Section 121485, if the parent, guardian, or other adult who has assumed responsibility for his or her care and custody in case of a minor, or the person seeking admission, if an emancipated minor, provides to the governing authority an affidavit stating that the examination required to obtain the certificate is contrary to his or her beliefs. If at any time there should be probable cause to believe that the person is afflicted with active tuberculosis, he or she may be excluded from the school or other institution listed in Section 121485 until the governing board is satisfied that he or she is not so afflicted.

Article 6.5. Newborn and Infant Hearing Screening, Tracking, and Intervention Program .... 124115-124120.5
124116.5.
   (d) This section shall not apply to any newborn whose parent or guardian objects to the test on the grounds that the test is in violation of his or her beliefs.

Newborn Eye Pathology Screening .... 124111-124112
HEALTH AND SAFETY CODE SECTION
124112.
   (d) Any screening examination recommended pursuant to subdivision (a) shall not be conducted on a newborn if a parent or guardian of the newborn objects to the examination on the grounds that the examination conflicts with the religious beliefs or practices of the parent or guardian.

Newborn Screening ... 125000-125002
[phenylketonuria and other preventable heritable or congenital disorders]
125000.
   (d) This section shall not apply if a parent or guardian of the newborn child objects to a test on the ground that the test conflicts with his or her religious beliefs or practices.

Prenatal Testing ... 125050-125119.5
125110. The Maternal and Child Health Program Act (Section 27) shall not apply if the pregnant woman objects to the test required by that act on the ground that the test conflicts with her religious beliefs or practices.
Summary of commonly used forms
and links to State Regulations.
Note: for details of each section Click Here.

Handbook of Daycare Vaccination Requirements:
http://www.dss.cahwnet.gov/getinfo/pdf/ccc5.PDF


Daycare Exemption Info:
http://www.dss.cahwnet.gov/getinfo/pdf/ccc5.PDF
on page 115 of document.

Exemption form Link, childcare and K-12:
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/pm286b.pdf


School Vaccination Requirements K-12:
http://www.cdph.ca.gov/programs/immunize/Documents/IMM-365D.pdf


Higher Ed Vaccination Requirements:
http://www.cdph.ca.gov/programs/immunize/Documents/IMM-1014.pdf


Higher Ed Exemption Info:
California does not have a state exemption form for college students. Ask the college for an exemption form. If they do not have one write a letter or affidavit stating the vaccine is against your beliefs. See page D-76 of
http://www.cdph.ca.gov/programs/immunize/Documents/IMM-365D.pdf
[The link at the top of this paragraph]
A few colleges have their forms online, Click here.

State Dept of Health Link
(Vaccination Program including exemption information):
http://www.cdph.ca.gov/programs/immunize/Pages/Default.aspx


Following paragraphs are a
BREIF Description of Recent Law Changes and any state health department or legislative links that would be helpful to document:

Information on new Tdap booster shot requirement for 7th through 12th grade students. Exemptions permitted for verified medical conditions or personal beliefs.
http://www.cdph.ca.gov/programs/immunize/Documents/EarlyAlertToSchools-AB354.pdf

More info is in our VacLib FAQ on Tdap CDPH8261 form, found here.

AB499 was passed and signed by Governor Brown. The new law allows minors 12 years old and older to consent to vaccines for sexually transmitted diseases without the knowledge or consent of their parents. This includes HPV Vaccine and any vaccines approved in the future.
http://www.leginfo.ca.gov/pub/11-12/bill/asm/ab_0451-0500/ab_499_bill_20111009_chaptered.html

SECTION 1. Section 6926 of the Family Code is amended to read:
6926. (b) A minor who is 12 years of age or older may consent to medicalcare related to the prevention of a sexually transmitted disease.
State Immunization Tracking System info:
http://cairweb.org/


Immunization Tracking System opt out info:
Patient and Parent Rights
http://cairweb.org/images/docs/SIISDisclosureform_MedicalOfficeHandout_REV62111.pdf

It's your legal right to ask:
  • Not to share your (or your child's) registry shot records with others besides your doctor.

  • Not to get shot appointment reminders from your doctor's office.

  • To look at a copy of your or your child's shot records, who has seen the records or to have the doctor change any mistakes.

Form to decline having your child’s immunization information shared:
http://cairweb.org/images/docs/CAIRDeclineFormNewFax.pdf



Information below on the left with a yellow background is Specific to your state. Information below on the right with a light grey/blue background is general information.
Page_Navigation_Links
New Born
California State specific information

Religious Exemption from newborn screening allowed. Cal. Health & Safety Code § 125000

Cal. Health & Safety Code § 125000(d)
(d) This section shall not apply if a parent or guardian of the newborn child objects to a test on the ground that the test conflicts with his or her religious beliefs or practices.

NewBorn Birthing Plan and Birth Exemptions
BirthExemptions  |   Birthing_Plans  |   Vitamin_K  |   Hepatitis_B  |   Eyedrops  |   Newborn_Screening

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.

Steps:
  • Create the Birthplan. Or modify one of our ours to fit your state laws and any other personal circumstances. (see below)

  • Sign the birthplan in front of a Notary.

  • Submit the birth plan to your hospital or midwife. Keep a couple extra copies in case plans change.

  • Make sure affected parties (doctors, nurses, etc) understand your requirements and wishes.

  • Plan on having one or two trusted persons stay with the mother and child to watch the child at all times while in the hospital, so no unwanted injections are given the baby.

  • The birth plan arrangements and letter should be turned in before delivery date.

  • The "Refusal to Permit Medical Treatment" form below is optional.

  • The "Refusal to Register Live Birth" form below is also optional.

Birth Plans (To be used with hospitals and/or midwives)
(Links to model birth plan letters)

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...

Information on the Dangers of Hospital Birth and the Benefits of Home Birth from gentlebirth.org

Our best and most itemized birthplan:
Word-Document (.doc) birthplan-itemized.doc  |   PDF-Document (.pdf) birthplan-itemized.pdf

(HTML) BirthPlan-Itemized for reading on screen. Includes handy small dictionary of terms in the document.

Word-Document (.doc) Model Letter for Hospital Births (Model11425.doc)

Model Birth Plan Letter for Hospital Births. This one is more detailed.

Word-Document (.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)
Word-Document (.doc) Model letter for hospital births for adoptions.doc


The birth plan arrangements and letter should be turned in before delivery date.
This "Refusal to Permit Medical Treatment" form below is optional.

"Refusal to Permit Medical Treatment" form
A generic form.
PDF-file (.pdf) letters/refusal_treatment.pdf


It would be good idea to use the AFFIDAVIT below AND a model birth plan letter from above above.
Affidavit - Birth Exemptions
HTML (simple text) Affidavit to modify.

AFFIDAVIT in Microsoft Word Word-Document (.doc) format. (may be modified)

If your Title and Paragraph number of your state law is not pasted to the left, click here for the link to your state law.
California State specific information
VITAMIN K ADMINISTRATION: Every neonate should receive a single parenteral 0.5-1.0 mg dose of vitamin K oxide or phytonadione (AquaMEPHYTON®) within 1 hour of birth for prevention of vitamin K deficiency bleeding (Hemorrhagic Disease of the Newborn). Occasionally parents will refuse vitamin K or request oral administration.
If parents persist in their refusal, they must sign the "Refusal to Permit Medical Treatment" form. These forms are kept in the file cabinet behind the unit clerk's desk in the WBN.


Vitamin K Injection...

The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert.
http://fdb.rxlist.com/drugs/drug-9003-Aqua-Mephyton+Inj.aspx?drugid=9003&drugname=Aqua-Mephyton+Inj
"The injectable form of vitamin K can rarely cause severe (sometimes fatal) allergic reactions when given by injection into a muscle or vein. Therefore, vitamin K should be injected into a muscle or vein only when it cannot be given by injection under the skin or taken by mouth, or when your doctor has judged that the benefit is greater than the risk. Seek immediate medical attention if you experience symptoms of an allergic reaction such as rash, itching, swelling, dizziness, or trouble breathing."
Potential exists for the newborn to experience hypersensitivity to any component of this medication.
Each milliliter contains: Phytonadione ............. 2 mg or 10 mg
Inactive ingredients:
Polyoxyethylated fatty acid derivative ................... 70 mg
Dextrose...................................................................... 37.5 mg
Water for Injection, q.s. .................................................. 1 mL
Added as preservative: Benzyl alcohol ...................... 0.9%

Links to prescribing information for Vitamin K:
http://vaclib.org/chapter/inserts.htm#vitK

Archive: Year 2002 Merck Vitamin K Package Insert - Aquamephyton PI | posted on Scribd

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

Or buy direct from Amazon.com:

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.

More Information:
Daily Med - Package Insert:
http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=e8808230-2c44-44c6-8cab-8f29b6b34051

VRM: First Strike – The Dark Side of The Vitamin K Shot
http://vaccineresistancemovement.org/?p=6547

Hepatitis B Vaccine
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 by asking hospital personal to sign the following waiver. Usually, you'll never find anybody in the hospital to sign this simple form, but you well get relief from demands to vaccinate your child.

"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.

See Birth Plans for more information on avoiding Hep B Vaccination at birth
State specific information
California Specific Information
EYE PROPHYLAXIS against gonococcal opthalmia neonatorum is mandatory for all neonates. A 1-2cm ribbon of sterile ophthalmic ointment containing 0.5% erythromycin should be administered within 1 hour of birth. Although California state law mandates neonatal eye prophylaxis, parents who refuse may sign a special waiver. This form is entitled "Refusal to Allow Treatment of Eyes of Infant with Prophylactic-Efficient Agent" and is located in the cabinet behind the unit clerk's desk in the WBN.

Eyedrops
Some states require Prophylaxis against Gonococcal OPHTHALMIA NEONATORUM.

A discussion of medical and legal issues regarding Silver Nitrate in the eyes of the newborn is here:
PDF file: Statutory Law USA: Requiring Silver Nitrate in Eyes of Newborns at: http://www.rbs2.com/SilvNitr.pdf
Written by Dr. Ronald B. Standler, attorney in Massachusetts and consultant

Blog type discussion of pros and cons of eyedrops for newborn is here: http://answers.google.com/answers/threadview/id/20050.html

State specific information
California Specific Newborn Screening
Notice of Information and Privacy Practices (CDPH)
http://www.cdph.ca.gov/HealthInfo/Documents/NPP Newborn Screening English.pdf


New Born Screening
U.S. states now require screening of newborn babies for specific diseases.

Conditions and legal status of "requirement" of newborn to be screened for each state:
National Newborn Screening Status Report - http://genes-r-us.uthscsa.edu/nbsdisorders.pdf

Newborn Genetic Screening Privacy Laws
(includes links to laws for various states)
Archived Copy: http://web.archive.org/web/20130603035608/http://www.ncsl.org/issues-research/health/newborn-genetic-and-metabolic-screening-laws.aspx

Newborn screening From Wikipedia, the free encyclopedia
http://en.wikipedia.org/wiki/Newborn_screening

Federal NewBorn Screening Law (from Families of Spinal Muscular Atrophy)
http://www.fsma.org


Page_Navigation_Links
Waivers: Read - Modify or Do Not Sign
Waivers - Take Care In Signing
If you take your new baby to an MD as opposed to a naturopath and/or chiropractor, please be aware of and careful of any forms you sign.

Our WARNING below is about signing (some) state approved and AAP created forms. See this letter from our director, Ingri Cassel, before you consider signing waiver forms.

WARNING!

To ALL who choose to partially vaccinate or NOT vaccinate their children:

We (here in Idaho) are hearing more reports of schools and daycares across our state not honoring legal and valid vaccine exemptions. The following article contains very important information as to why you do NOT want to sign AAP's (state adopted) exemption form: http://childhealthsafety.wordpress.com/2014/03/04/
why-you-must-not-sign-a-refusal-to-vaccinate-form-at-least-if-you-want-to-keep-your-kids-that-is/


Filing a NO Vaccination Notice with Instructions.pdf - (http://forohioans.wikispaces.com)

Older letter regarding exemptions in Idaho (similar to many states today)

Dear VacLib Members and Friends -

Wanted to give you all a heads up on state issued exemption forms. I haven't had to deal with this personally for several years, and I always crossed out sentences or clauses, and often adding some of my own, before signing their exemption of medical release type of forms. When Donna Carrillo began to diligently search out existing exemption forms and posting them, I read over a couple of them and encouraged people to make up their own whenever possible. After having a "closer encounter" with such a form - a form provided to the state of Idaho by the American Academy of Pediatrics and the Centers for Disease Control and Prevention and used by licensed Idaho daycares, I was shocked into the VERY REAL danger of signing these forms without changing them significantly.

Any form one affixes their initials to, dates and affixes their signature to at the end is a LEGAL document. All statements prior to your signature you must agree to fully OR restrict your signature to say that you are signing under TDC - threat, duress, and coercion. The form that my daughter was told she needed to fill out for this daycare is posted here: ChildCareExemptForm.pdf ChildCareExemptForm.pdf. On this form, she crossed out all the "nots" and in her personal statement she further clarified that she understands fully the risks of vaccinating her child.

I have since found out that most public schools and daycares in other states also use a similar form. Basically, by initialing and signing this form as is, you are admitting to understanding that "vaccine preventable" diseases are extremely deadly and ALSO admitting to negligence for willfully denying your son/daughter the life saving protection that vaccines offer. These forms are MEANT to not only be intimidating but to catch the legally ignorant off guard. This is very serious to me since all states have adopted the federally funded Child Abuse Prevention and Treatment Act which gives states the right to literally steal your children for up to 48 hours -- the time they have to prove child neglect OR abuse.

If it were ME, I would insist that they accept a form that I provide them since it satisfies the law. If there are any problems or they insist on me using their form, I would cite the law and ask the school or daycare provider where it actually says in state statute that this particular form is the only form that will satisfy the law. Since your parental rights are at stake here, it is best to be vigilant and err on the side of being overly cautious.


A modified AAP form is posted here that you may wish to use with your doctor: AAPmodified.htm

AAPmodified.doc MSWord .DOC file  |   AAPmodified.pdf PDF file, best for printing.

Not all State employees are aware of the law and many exhibit the Hitler Complex. Take a firm stand. Some individuals have had difficulty getting the required forms. Such arrogance on the part of State employees should be reported to the Director of your state Department of Health.

See:   AnaiRhoads.org Why Signing a Waiver to Avoid Vaccines Can Be Considered Abuse
She is referring to the Refusal To Vaccinate From developed by The American Academy of Pediatrics, not a regular religious or conscientious exemption letter or form.


Page_Navigation_Links
Letters Forms Affidavits
Links to Model birth plan letters (above).

Link to Refusal to Permit Medical Treatment form

Links to Affidavit - Birth

An Adult Affidavit, with Christian beliefs, is here. (MSDOC file) Feel free to modify as needed.


Dr. Tenpenny has the following forms on her web site. The forms are generic and may be used in any state.

Affidavit for Parents Participating in International Adoption (Word) (pdf)
Hep B vaccine in hospital for newborn refusal, sample (pdf)
OSHA Declination Statement Form (also, pdf)
Religious exemption letter that was approved in Florida (Word) (pdf)
School Vaccine Exemption Form, sample (Word) (pdf)
TB testing refusal, sample (pdf)
Childcare and School Immunization Requirements

http://drtenpenny.com/forms/

Sample Vaccine Letters. from www.vaccines.bizland.com/letters.htm archived on VacLib.org/letters/doctor.htm

Short Sample Vaccine Letter

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.

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!
An index page to various Acceptance of Responsibility) forms is here:
. http://www.vaclib.org/legal/accept.htm

Religious exemption forms will be listed below under Daycare Schools Colleges

Did not find your state exemption form on our site?
Then try this link to forms for all 50 states and D. of Columbia.
http://experimentalvaccines.org/vaccine-exemption-forms/


Page_Navigation_Links
DayCare - Preschool - Schools - Colleges
DayCare - Preschool - Schools - Colleges
(.pdf)
Vaccine & TB test exemption is in Spanish on back of form.
PM 286 B (1/02) California School Immunization Record (fill-in)

Alternate Link:
http://www.cdph.ca.gov/programs/immunize/Documents/pm286b.pdf


State Form Required: "No."
However,while CA statute law does not require a specific form there is a relatively new form for grades 7-12 (Pertussis) that CDPH says is required:
http://vaclib.org/exempt/states/ca/FAQ-CDPH8261.htm

Commonly used links to:
Daycare Vaccination Requirements, Daycare Exemption Info, K-12 Immunization Requirements, Exemption Form PM286B, College Immunization Requirements, DOH link, Recent Law Changes and Tracking Registry Opt-out info. Here.

DayCare-Preschool-K-12-Colleges
DayCare  |   Preschool  |   K thru 12  |   Colleges

DayCare
(.pdf)
Vaccine & TB test exemption is in Spanish on back of form.
PM 286 B (1/02) California School Immunization Record (fill-in)

Alternate Link:
http://www.cdph.ca.gov/programs/immunize/Documents/pm286b.pdf

(.pdf) California Generic Exemption for all schools

Commonly used links to:
Daycare Vaccination Requirements, Daycare Exemption Info, K-12 Immunization Requirements, Exemption Form PM286B, College Immunization Requirements, DOH link, Recent Law Changes and Tracking Registry Opt-out info. Here.

Rosamond Bible Preschool
Exemption from Immunization form [Archived]
(.doc) http://www.rbpsol.com/Forms/Immunization.doc

Waiver of health examination. Page 1 is English, Page 2 is Spanish.
(.pdf) http://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSvcForms/pm171b(bi).pdf.

Another source for the Health Examination waiver form
(.pdf) http://www.ieminc.org/Enrollment/Health%20Waiver.pdf

AFFIDAVIT for California Older Child (for daycare, preschool or school)

Note: In California, vaccine exemptions come under the broad term, "Personal Beliefs Exemption" (PBE) and thus a wide range of beliefs are protected. Our affidavits may be modified to reflect beliefs other than what we provide as an example.
California Older Child HTML SAMPLE Affidavit   |   Information: Calif Code snips


Preschool
See Daycare above.

Kindergarten & Schools
Commonly used links to:
Daycare Vaccination Requirements, Daycare Exemption Info, K-12 Immunization Requirements, Exemption Form PM286B, College Immunization Requirements, DOH link, Recent Law Changes and Tracking Registry Opt-out info. Here.

Important:
July 1, 2011 a new Tdap booster vaccine is required to enter California schools, grades 7-12. Both the medical and Personal Beliefs Exemption (PBE) are available. Schools have been given a new form, CDPH 8261 to be used for the Tdap booster. Click here for our FAQ on CDPH 8261.


Links to CA state vaccine exemption form may be found above, Click here for PM 286 B.

Sample Letter for School Vaccination Waiver
Download: (.doc) California School Vaccination Waiver

Sample Letter for School Vaccination Waiver WWW.churchstate.org



California Exemption letter written by Adventist Church Council member.
(For TB exemptions, you may use the CA state form PM 286 B below:)
and/or modify one of the letters below in the TB section)
(.pdf)
Vaccine & TB test exemption is in Spanish on back of form.
PM 286 B (1/02) California School Immunization Record (fill-in)

Alternate Link:
http://www.cdph.ca.gov/programs/immunize/Documents/pm286b.pdf


Commonly used links to:
Daycare Vaccination Requirements, Daycare Exemption Info, K-12 Immunization Requirements, Exemption Form PM286B, College Immunization Requirements, DOH link, Recent Law Changes and Tracking Registry Opt-out info. Here.

VALLEY CHRISTIAN ELEMENTARY SCHOOL
HEALTH EXAM FORM
IMMUNIZATION EXEMPTION FOR PERSONAL BELIEFS:
Bottom of page 1, sign and date.
(.pdf) http://www.dublinvcc.org/schools/elmentary/forms/health_form.pdf

Waiver of health examination. Page 1 is English, Page 2 is Spanish.
(.pdf) http://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSvcForms/pm171b(bi).pdf.

Another source for the Health Examination waiver form
(.pdf) http://www.ieminc.org/Enrollment/Health%20Waiver.pdf


SELF-REALIZATION FELLOWSHIP Youth Program
3880 San Rafael Avenue, Dept. 9W
Los Angeles, CA 90065-3298
'Our child is exempt from the immunization requirement based on an affidavit we signed stating that immunization is contrary to our beliefs. We understand and agree that in case of an outbreak of any one of the diseases for which immunization is required, our child may be temporarily excluded from attending the Youth Program for his/her protection and for the protection of others.'
__________________________      __________________________
Parent/Guardian Signature                     Date

2nd page on the health form
(.pdf) Youth-Program-Application.pdf

Sample: California Exemption letter.

Colleges/Universities
Higher Ed Vaccination Requirements:
http://www.cdph.ca.gov/programs/immunize/Documents/IMM-1014.pdf


Higher Ed Exemption Info:
California does not have a state exemption form for college students. Ask the college for an exemption form. [A few links to college forms are below.] If they do not have one write a letter or affidavit stating the vaccine is against your beliefs. See page D-76 of
http://www.cdph.ca.gov/programs/immunize/Documents/IMM-365D.pdf
[The link at the top of this paragraph]

ONLINE FORMS:

CA State Fullerton University Hep B and MMR vaccine waiver form
(.pdf) http://www.fullerton.edu/shcc/pdfs/Waiver_Form.pdf

University of Southern California
(OLD/Archived) HEPATITIS B VACCINATION DECLINATION FORM (University Students)
(.pdf) (OLD/Archived) HEPATITIS B VACCINATION DECLINATION FORM
http://web.archive.org/web/20050130074431/studenthealth.ucsd.edu/pdfdocs/hepbreqstatement.pdf

Humboldt State University
Student Health Center
Arcata, CA 9552
Immunization Form
Exemption request bottom of page 2.
(.pdf) http://www.humboldt.edu/forms/sites/forms/files/Immunization%20Requirements%202013_0.pdf

AFFIDAVIT for California Adult (college religious exemption) ... Edit as needed...
You may use this for employment situtations as well.

Note: In California, vaccine exemptions come under the broad term, "Personal Beliefs Exemption" (PBE) and thus a wide range of beliefs are protected. Our affidavits may be modified to reflect beliefs other than what we provide as an example.
California Older Child HTML SAMPLE Affidavit   |   Information: Calif Code snips


An Adult Affidavit, with Christian beliefs, is here. (MSDOC file) Feel free to modify as needed.

Page_Navigation_Links
OptOutRegistry for Vaccines
and various other Opt-Outs
California State specific information
Vaccine Registry Opt-Outs:

Immunization Tracking System opt out info:
Patient and Parent Rights
http://cairweb.org/images/docs/SIISDisclosureform_MedicalOfficeHandout_REV62111.pdf

It's your legal right to ask:
  • Not to share your (or your child's) registry shot records with others besides your doctor.

  • Not to get shot appointment reminders from your doctor's office.

  • To look at a copy of your or your child's shot records, who has seen the records or to have the doctor change any mistakes.

Form to decline having your child’s immunization information shared:
http://cairweb.org/images/docs/CAIRDeclineFormNewFax.pdf


Vaccine Registry Opt-Outs:

KNOW YOUR RIGHTS
Confidentiality of Your Child’s Vaccination Records
FERPA: The Family Educational Rights and Privacy Act
http://www.vaxchoicevt.com

     - - - - Other Opt-Outs - - - -:

Birth Certificate and Marriage License Opt-Out:

Did you know that you can REFUSE to sign the hospital birth certificates and that there is no law that requires you to do so?
See: Marriage Licenses, Birth Certificates & #SSNs

Military Recruiters:

STUDENT OPT OUT FORM regarding the
RELEASE OF NAME, ADDRESS, AND TELEPHONE NUMBER TO MILITARY RECRUITERS
(.pdf) Archived letter from www.militaryfreeschools.org

UNDERGROUND ACTION ALLIANCE STUDENT OPT OUT FORM
Word-Document (.doc) Archived on VacLib.org: http://veterans4peace.org/opt_out.doc

SAMPLE ENGLISH - BILINGUAL FORMS FOR OPTING OUT
Act to Protect Your Privacy from Military Recruiters
Information links and forms at AFSC site

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-file (.pdf) http://www.catholiccitizens.org/content/img/f26422/opt%20out%20notice.pdf

STUDENT OPT-OUT NOTICE - Google Search

Employment
California State specific information

Note: Hospital Health Care Workers in California may opt out of yearly influenza shots.
California Health Care Workers
Source: http://www.cdph.ca.gov/programs/immunize/Pages/CaliforniaHospitalInfluenzaLaw.aspx

California Hospital Influenza Law

With the chaptering of SB 739, the California Health and Safety Code will read effective January 1, 2007.

1288.7. By July 1, 2007, the department shall require that each general acute care hospital, in accordance with the Centers for Disease Control guidelines, take all of the following actions:
(a) Annually offer onsite influenza vaccinations, if available, to all hospital employees at no cost to the employee. Each general acute care hospital shall require its employees to be vaccinated, or if the employee elects not to be vaccinated, to declare in writing that he or she has declined the vaccination.
(b) Institute respiratory hygiene and cough etiquette protocols, develop and implement procedures for the isolation of patients with influenza, and adopt a seasonal influenza plan.
(c) Revise an existing or develop a new disaster plan that includes a pandemic influenza component. The plan shall also document any actual or recommended collaboration with local, regional, and state public health agencies or officials in the event of an influenza pandemic.

For the text of the entire bill, see http://www.leginfo.ca.gov/pub/05-06/bill/sen/sb_0701-0750/sb_739_bill_20060928_chaptered.html

Download: (.doc) California Adult Vaccine Exemption

California Exemption letter written by Adventist Church Council member.
CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
HEPATITIS B VACCINE DECLINATION FORM (University Employees) OSHA
OLD
(.pdf) 1st Web Archive Link
(.pdf) 2nd Web Archive Link
(.pdf) 3rd Web Archive Link
(.pdf) 4th Web Archive Link

Stanford University - Stanford, California
Hepatitis B Vaccine Declination Form (University Employees)
(.pdf) http://www.stanford.edu/dept/EHS/prod/researchlab/bio/docs/Hepat_BVacc_Decl.pdf 

TB Test: Yes; mandated.

However, exemption is allowed, and the exemption is on the back of the CA immunization record pm286b. (.pdf) http://www.cdph.ca.gov/programs/immunize/Documents/pm286b.pdf

University of California, Berkeley - Graduate School of Education - TB Skin Test required.

TB Testing Exemption Letter:
OSHA
Standard Interpretations
09/23/1997 - The Bloodborne Pathogen Standard and the Enforcement Procedures for TB.
"Finally, be aware that participation in the employer's skin testing program is voluntary on the part of the employee. OSHA does not require that employees participate in TB skin testing, only that the employer make such skin testing available to employees."
See TB Testing for more information.

US Fish and Wildlife Service Form 3-2283
Hepatitis B Immunization Consent/Refusal Form
PDF-file (.pdf) http://www.fws.gov/forms/3-2283.pdf


Page_Navigation_Links
TB and/or Lead Testing
State specific information
TB-Links/Exemptions

California Specific w/California Health and Safety Code 121475 (b)
HTML [California]
Sample Letter for exemption to TB testing - California TBCalif.htm
MS DOC
Sample Letter for exemption to TB testing - California TBCalif.doc
WordPerfect
Sample Letter for exemption to TB testing - California TBCalif.wpd
PDF
Sample Letter for exemption to TB testing - California TBCalif.pdf

Generic letter for Exemption to TB Testing:
HTML (text): Exemption-tb-test.html

MS Doc file: Exemption-tb-test.doc

OSHA
Standard Interpretations
09/23/1997 - The Bloodborne Pathogen Standard and the Enforcement Procedures for TB.
"Finally, be aware that participation in the employer's skin testing program is voluntary on the part of the employee. OSHA does not require that employees participate in TB skin testing, only that the employer make such skin testing available to employees."

School Employees: (TB test)
Regarding legal requirement, Optional tests and X-ray final determination.
http://law.justia.com/codes/california/2009/hsc/121525-121555.html


The CDC approves, the skin test, and TB blood tests.

Religious Exemption for School Employees: (TB test)
EDUCATION CODE SECTION 49400-49415

49406.
    (g) If the governing board of a school district determines by resolution, after hearing, that the health of pupils in the district would not be jeopardized thereby, this section shall not apply to any employee of the district who files an affidavit stating that he or she adheres to the faith or teachings of any well-recognized religious sect, denomination, or organization and in accordance with its creed, tenets, or principles depends for healing upon prayer in the practice of religion and that to the best of his or her knowledge and belief he or she is free from active tuberculosis. If at any time there should be probable cause to believe that the affiant is afflicted with active tuberculosis, he or she may be excluded from service until the governing board of the employing district is satisfied that he or she is not so afflicted.

TB-Links/Exemptions

Generic letter for Exemption to TB Testing:
HTML (text): Exemption-tb-test.html

MS Doc file: Exemption-tb-test.doc

OSHA
Standard Interpretations
09/23/1997 - The Bloodborne Pathogen Standard and the Enforcement Procedures for TB.
"Finally, be aware that participation in the employer's skin testing program is voluntary on the part of the employee. OSHA does not require that employees participate in TB skin testing, only that the employer make such skin testing available to employees."
TB and Lead Testing Links:
F L Y E R    LETTER    Exemption_Letters    OSHA_and_TB_test    Tubersol    Treatment    TB_Screening    Alternatives/Additional_Information

The above TB and Lead exemption letters are courtesy of Deirdre DeVane of Wash DC. Thank you Deirdre!
The adult TB letters were edited by Sherri Tenpenny. Thank you Sherri!

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.

See below in Misc some QXCI, etc practitioners.

Misc Info - QXCI - Etc.
Here are some of the practitioners for California

California BEST™ BioMeridian Practitioners:

Mary Kennedy, MA MA
Master/Teacher
Encinitas, California
760-633-3359
grevelle@onemain.com
New! Meridian Stress Assessment - Find out if your organ systems and meridians are in balance using FDA registered technology. If you're out of balance, we can find remedies to assist you in rediscovering your optimum health.

Ross Life Centers
Dr. Calvin B. Ross, D.C.
Chiropractor in San Clemente
653 Camino De Los Mares, Suite 103 San Clemente, California, 92673 USA
Telephone (949) 661-9476 or 800-386-3929 - (24 Hr. Answering Service)
FAX (949) 661-7536 - (24 Hr. Fax Line)
http://www.drrossdc.com/
Email: info@DrRossDC.com
Specializing in the Meridian Stress Assessment, (MSA), which is FDA approved.

Jace Wellness Center
Craig Jace, DOM, L.Ac., PA-C, ND
10843 Mangolia Blvd, Ste 1
No. Hollywood, CA 91601
Phone: (818) 505-8610
http://www.jacemedical.com
E-mail: drj@jacemedical.com

BioSET™ Institute
Ellen W. Cutler, D.C.
Post Office Box #3
Mill Valley, CA 9494
Phone:
Toll-free: (877) 927-0741
Local: (415) 384-0200
Fax: (415) 384-0199
http://www.drellencutler.com/
E-Mail: admin@bioset-institute.com
BioSET "incorporates muscle testing, detoxification, enzyme therapy, acupressure and the use of Biomeridian's MSA (meridian stress assessment) machine."

American Herbal Laboratories, Inc.
Dr. Luke Cua, P.H.D., O.M.D., L.A.C.
8526 E. Garvey Ave.
Rosemead, Ca 91770
Tel: (800) 307-0928, (626) 307-0928
Fax: (626) 307-9445
http://www.newvita.com/
Email: herbal@newvita.com

Izabela Dimitrova N.D.
Bio Meridian Stress Assessment, Nutritional Counseling, Homeopathy, Herbology
120 S. Swall Dr. Suite 105
LA, CA 90048
Tel: 323 841 2575
Email: beladimitrova@yahoo.com

E-Z Health, Inc.
Nectar of the Universe

Patrick Estes & Munie Juan
3243 Balboa St, San Francisco, CA 94121
415-379-3504
Fax (415) 379-3504
http://www.nectaroftheuniverse.com/msa.php
ezhealth@sbcglobal.net

Dr. Glen Canale
P.O. Box 366
Idyllwild, CA. 92549
USA
P/F +1-909-659 5817
I use several machines in my practice including: EAV, Cymatic Therapy, Molecular Enhancement, Amythst Regenerator, Oxone Therapy, Ray Light Beam, F-Scan, Audio Visual Stimulation, Voice Analysis, QGM Machine, Color Therapy, Swing Master, Juice Therapy, Mini Thumper. I have been trained in Russia, Ukraine, England, and the U.S. My Doctorate is in Cymatic Therapy. I use the Clark Therapy with the use of the F- Scan machine.

California QXCI Practitioners:

http://www.hope4cancer.com
A clinic in Mexico (Playas de Tijuana, Mexico) which treats cancer and a variety of other aliments. Click on link for available modalities which include Oxygen, Chelation, Electronic Homeopathy, Micor-current Therapy, Rife, Color, etc. They use the QXCI equipment also.

Northern California

Haripriya Dillon
Specializes-Homeopathy, Flower Essences, Herbology, Aromatherapy
Penn Valley, Ca 95946
530-432-2173
haripriya@earthlink.net
Web Address:http://www.bluegreenalgae.com

Ariana Gossfeld
Specializing in flower essences, emotional therapy, gemmotherapy (cellular drainage) and oligo therapy (trace mineral for increased enzymatic activity).
Boulder Creek, CA 95006
831-338-1982
arianaqx@earthlink.net

Lindalee Hatch, CBT, CMT
Certified Biofeedback Therapist, Certified Massage Therapist,
EPFX / QXCI Practitioner
Physical Health and Balance
Fees:
$150 initial 2 hour session
$75 per hour following sessions
Sacramento, CA
916-929-0424

Mary Ann Reith, RN, CBT
House energy clearing
Work with animals
In person or phone consultations available
San Leandro, CA
510-351-5533

Tisha Rivias
EPFX / QXCI Practitioner
Dark Field. Microscopy, Nutrition Massage
Silicon Valley, San Jose, Carmel, Montery, Santa Cruz, Salinas, Central and Northern California
831-710-0091
qxci4all@yahoo.com

Robin Grant
Certified Biofeedback Technician (SCIO/EPFX)
Certified NLP Master Results Coach & Trainer
EFT & Touch for Health Practitioner
San Jose, CA
Cell: 408-316-2079
www.robin-grant.com

Cary Howard, PhD
Consultant in Human Behavior, Certified Clinical Hypnotherapist, Certified Biofeedback Therapist, EPFX / QXCI Practitioner
Habit Control, Expanding Consciousness, Accelerating Learning Skills, Personal Problem Solving, Stress Management Self Help Programs
Fees:
$125.00 for 1 1/2 hour session
Santa Rosa CA
707-538-0547
(cell) 707-483-3261
choward@sonic.net

The Quantum Alliance Inc.
Chandra Giovanni
CONTACT:
Voice Mail: 408-278-5696
Cell: 408-316-7955
Email: cg@quantumsource4life.com
Southern California

Vivien Bonzo
EPFX / QXCI Practitioner
Alternative Healing Technologies to address your needs
Fees:
$250 EPFX / QXCI three hour session
$150 1 1/2 hour session
$175 3 hour distance session
$100 1 1/2 hour distance session
$50 problem specific "mini-session" (distance only)
Los Angeles, CA
626-392-3133

Roopa Chari or Deepak Chari
San Diego, CA
858-689-0513
charicenter@aol.com

Ariana Gossfeld, CBT, CMT
Certified Biofeedback Therapist, Certified Flower Essence Practitioner, Certified Massage Therapist, Certified Triom Biomagnetics Instructor, EPFX / QXCI Practitioner
Spiritual and Emotional Counseling, Gemmotheraphy and Oligotherapy Counsleing
Fees:
$125 initial EPFX / QXCI session
$75 follow up session
$45 Flower Essence Session
$100 Massage
South Bay Area, Santa Cruz Mountain Area, Santa Cruz, CA
28388 Big Basin way
Boulder Creek, CA 95006
831-338-1982
arianaqx@earthlink.net

Marcy Jimenez, CBT
Certified Biofeedback Therapist, EPFX / QXCI Practitioner
Fees:
$150 First Visit
$100 Revisit
Tiujana, Mexico
San Diego, CA
mjmex@hotmail.com
Web Address: www.hope4cancer.com

Dr. HarHari Khalsa
1026 S. Robertson #300
Los Angeles, CA 90035
310-358-0120

Jenna Loren
EPFX / QXCI Health Practioner
Nutrional Therapy and Psychological Therapy
San Diego, CA 92008
760-729-6092

Brigham Lundahl
Alternative Pain Clinic
27251 Commerce Centre Dr. Suite B
Temecula, CA, 92590
909-506-9517

Michael Mohoric
Certified Qigong Teacher, EPFX / QXCI Practitioner
Stress Reduction, Pain reduction, Disease Prevention, Physical, Emotional, and Spiritual issues, Space Clearing
Fees:
$150 for the first, 2 hour session
$90 per hour for follow up sessions
Laguna Area, Orange County, North San Diego County, CA
949-716-2383
mmohoric@earthlink.net

Cheri Reeder, RN, CHT
EPFX / QXCI Therapist, EPFX / QXCI Trainer
Holistic Healing, Reflexology, Reiki Master
Energy Balancing
San Diego, CA 92117
619-743-3181
Toll Free: 877-650-5400

Judy Smith ND, NMD
Body Health
Detox, rebuilding and renewal since 1996
We work with pets too!
New Port Beach/ Costa Mesa, CA 92707
714-662-7613

Herb Stockman, CBT
EPFX / QXCI Practitioner, Certified Biofeedback Therapist
Fibromyalgia, Leaky Gut Syndrome, Chronic Fatigue
Fees:
$125 Initial Calibration
$65 per hour for further sessions or two sessions at $55 each
Irvine, CA
949-857-9394
hstockman@aol.com
Web Address: www.quantum-biofeedback.net

http://www.theqxci.com/practitioners.php#northcalifornia

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 1-407-672-6144.
General Information
QXCI SCIO EPFX Overview
(The SCIO and the EPFX are the same device.
It is known as the EPFX in the USA and the SCIO world wide.)
Source:
http://www.energymedicinereview.com/qxci-scio-epfx.html

National (USA) search results for EPFX (QXCI) / SCIO Practitioners.
http://www.alternativesforhealing.com/cgi_bin/practitioner-epfxqxciscio.php


Use Google or other search engine to find a BioMeridian Practioner in your area.

If you do not find one near you, you might use this contact page:
http://biomeridian.com/contact.htm

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