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Vaccination Liberation Information
Georgia State Exemption Page
VacLib.org & VaccineTruth.net Exemption Page

Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

Statutes/Laws
Link to state law.
National Vaccine Information Center:
Link to state law.


Exemptions 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.

For additional help with exemptions, birth plan,etc questions:
Non_Vaccinating_Physicians

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  &  Religious

PDF documents (.pdf)

A PDF reader is required for PDF Files:
Free Foxit Reader 12 MB file size.

Or Free Download of Acrobat Reader: [Adobe. 43 MB file size]


Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

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.

Birth Exemptions:

Religious Exemption from newborn screening allowed under
Ga. Code Ann. § 31-12-7

31-12-7.
(a) The department, or its successor agency or department, shall adopt and promulgate appropriate rules and regulations governing tests for phenylketonuria, sickle cell anemia, and sickle cell trait so that as nearly as possible all newborn infants who are susceptible or likely to have phenylketonuria, sickle cell anemia, or sickle cell trait shall receive a test for phenylketonuria, sickle cell anemia, or sickle cell trait, or all of such conditions as soon after birth as successful testing and treatment therefore may be initiated; provided, however, that this Code section shall not apply to any infant whose parents object thereto on the grounds that such tests and treatment conflict with their religious tenets and practices.
http://www.lexisnexis.com/hottopics/gacode/Default.asp [search for 31-12-7]

Newborn Screening for Metabolic and Sickle Cell Disorders Program

Screening: Parents Refusal

Religious grounds are the only valid reason for refusal of newborn screening. If a parent objects to testing based on religious grounds, a hospital official is to inform the parent of the consequences of refusal (possible infant death or retardation) and require the parent to complete a statement indicating their declination of newborn screening for religious reasons. This signed refusal should be retained in the record of the physician, midwife or individual attending the delivery.

http://health.state.ga.us/programs/nsmscd/screening_refusal.asp

IMPORTANT! Please download this if you're expecting a child or know someone who is!
Georgia Newborn Screening Manual for Metabolic Diseases & Hemoglobinopathies
A Practitioner’s Guide
Older Guide (has the sample refusal form)
(.pdf) [Archived on VacLib.org]
http://health.state.ga.us/pdfs/familyhealth/ganewbornscreening.98.pdf

On page 9 is the METABOLIC AND HEMOGLOBIN SCREENING NOTICE
I, the parent of Baby __________________________, understand that Georgia law requires that all infants born in Georgia have the Newborn Screening test performed, unless the parent’s object to such testing for religious reasons.
This proves to the hospital that religious exemption is allowed for newborn screening in Georgia.
Page 9 is a SAMPLE form, marked S A M P L E in big letters.
Sample Letter in PDF form.  |   Sample Letter in .DOC form.

New Guide
Quality Assurance/Quality Improvement for Public Health Nursing Practice Manual
(.pdf) http://www.health.state.ga.us/pdfs/nursing/QA-QIManual/Tab%204-Standards%20and%20Tools.pdf
No sample form is in the new guide. See old guide above to view sample refusal form.

If the link above does not work, check this page:
Maternal and Child Health Programs
http://health.state.ga.us/programs/family/publications.asp

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)

"... First Amendment of the US Constitution, Ga. Code Ann. § 31-12-7, and O.C.G.A. § 20-2-771 (4e) to receive Religious Exemption from Vaccination & testing.

If your Title and Paragraph number of your state law is not pasted above, click here for the link to your state law.

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. Or order directly from Amazon.com

Biotics Research, Bio-K Mulsion - 1 fl oz

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.


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

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


New Born Screening
See Birth Exemption for more Georgia specific information

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/sites/genes-r-us/files/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

Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

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!

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. 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 Form developed by The American Academy of Pediatrics, not a regular religious or conscientious exemption letter or form.


Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

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/


Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

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

DayCare
State Form Required: No. However, all exemption waivers must be notarized as required by law.
Download the Microsoft Word document here.
(.doc) VaccineTruth.net/letters/AFFIDAVIT for Georgia Child.doc
You may also use Exemption VacLib-GA.doc for daycare and preschool.


Preschool
State Form Required: No. However, all exemption waivers must be notarized as required by law.
Download the Microsoft Word document here.
(.doc) VaccineTruth.net/letters/AFFIDAVIT for Georgia Child.doc
You may also use Exemption VacLib-GA.doc for daycare and preschool.


Kindergarten & Schools
Exemption VacLib-GA.doc
(.doc) VaccineTruth.net/letters/ExemptionVacLib-Georgia.doc
(.wpd) VaccineTruth.net/letters/ExemptionVacLib-Georgia.wpd

Cobb County School District
Form JLC-4
WAIVER OF IMMUNIZATION REQUIREMENTS
DUE TO CONFLICT OF RELIGIOUS BELIEFS
(.doc) http://www.cobb.k12.ga.us/pinemountain/Form_JLC-4.doc‎

A letter that was used to exempt a child from Hep B vaccine...
Mrs. Jane Doe
123 Any Road
Your City, Georgia. 00000

School _________________________________________

Statement of Religious Objection to Immunization

In accordance with Georgia Immunization program O.C.G.A. § 20-2-771

I hereby certify that the administration of any vaccine and other immunizing agents to my child, ____________, is contrary to our personal Religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempted from the school immunization requirements as set forth O.C.G.A. § 20-2-771(e)

We believe in God, and that God has created us in his image. We are bestowed with His gift, the immune system. I believe it is sacrilegious and a violation of our sacred religious beliefs to violate what God has given us by injected our bodies with vaccines known to cause immune system damage.

We believe that God does not want us to harm our bodies. After much research we believe vaccine to be harmful to the body. They contain toxic ingredients (i.e. Thimerosal, Formaldehyde, Ethylene glycol, Phenol, etc.) that can weaken the immune system and cause illness, lasting damage or death. Many vaccines contain human aborted fetal tissue cells (i.e. Rubella, Chickenpox, Hep A, and some brands of injected polio). This is highly against our beliefs to use any part or benefit from anything doing with the abortion of a human life.

The Hepatitis-B vaccine was designed to protect 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 children. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of our faith. With all this, we believe that vaccination is against our personal religious beliefs and wrong in the eyes of God.

Parent __________________________________ Date _______________

Parent __________________________________ Date _______________

Subscribed and Sworn before me this _____ day of ___________, 20____.

________________________________________
Notary's Signature and Seal

O.C.G.A. § 20-2-771(e)

(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.

Sample Religious Affidavit found online...

Here is an example of a religious exemption I made up a few months ago. This one uses the Georgia Code as an example.

----------------------------------
An Example Affidavit

-First copy & paste the code from your state. Example follows:

[Education, Part III, Health, Ga. Code Ann. §20-2-771. Rules of Department of Human Resources Public Health, Ga. Comp. R. & Regs.§ 290-5-4-. 01 to .09.]

-Then copy & paste the section that pertains to religious exemption. Example:

[A child may be exempted on religious grounds if a parent furnishes an affidavit swearing that the immunization required conflicts with the religious beliefs of the parent. The immunization may be required in cases when such disease is in epidemic stages. O.C.G.A. § 20-2-771(e). Religious belief in divine healing through faith not to excuse refusal to have children vaccinated. son v. State, 84 Ga. App. 259, 65 S.E. 2d 848 (1951).]

-Then continue with the following:
Pursuant to the aforementioned (insert above code), I, the undersigned, declare the immunization requirements as set forth in O.C.G.A. § 20-2-771(e) contrary to my bona fide religious beliefs and request, as permitted by the law, an exemption from the immunization requirements of your institution for myself or the undersigned minor child under my legal care or guardianship.

NAME ______________________________________

SIGNATURE__________________________________

ADDRESS____________________________________

___________________________________________

PHONE_____________________________________

DATE_______________________________________


___ Check here if declaring exemption for a minor child and enter child's name below.


MINOR CHILD'S NAME _________________________________________

ADDRESS______________________________________

_______________________________________________

PHONE_________________________________________

DATE___________________________________________

----------------------------

**A nice, professional looking affidavit. BTW, they are not allowed to ask your religion.
__________________

**This can be copied to Wordpad & edited to your needs.

Note:   Exemption letters, affidavits, and statements must all be notarized in Georgia.
__________________

Cobb County School District
JF-5: Objection to the Use of Social Security Number
English
http://www.cobb.k12.ga.us/pinemountain/Form_JF-4_Eng.doc

Colleges/Universities
(.doc) VaccineTruth.net/letters/ImmunizationGeorgia11412.doc

ϑ RELIGIOUS EXEMPTION
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
__________________________________________________________________
Signature of student (required ONLY for religious exemption)         Date

Floyd College
3175 Cedartown Hwy., SE, P.O. Box 1864 - Rome, Georgia 30162-1864
CERTIFICATE OF IMMUNIZATION
Bottom of form, page 2.
Part III – Exemptions
I,____________________________________affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
(.pdf) https://www.applyweb.com/apply/floyd/immune.pdf

Berry College - 2277 Martha Berry Hwy NW • Mount Berry, GA 30149
Meningitis Vaccination Record/Waiver
(.pdf) http://www.berry.edu/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=7828&libID=7844
Check off the Religious Exemption at the bottom of the page of the form. Signature is required.
(.pdf) http://www.berry.edu/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=7827&libID=7843

EXEMPTIONS:
______ Exemption on grounds of permanent medical contraindication
______ Exemption on grounds of temporary medical contraindication
                ______ A. Pregnancy, expected delivery date: _____/_____
                ______ B. Other, anticipated date of contraindication's end: _____/_____
______ Religious exemption: I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs.

I understand that exemption for any of the reasons listed above subjects me to exclusion from campus in the event of an outbreak of a disease for which immunization is required.

Signature of Student:___________________________________________Date: ____/____/______

GEORGIA PERIMETER COLLEGE
Religious Exemption at the bottom of Page 2
(.pdf) http://www.gpc.edu/~je/pdf_files/Immunization%20Form.pdf

Gainsville College (check religious exemption at bottom of form) looks like this...
ϑ RELIGIOUS EXEMPTION
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.

Signature of Student (Student signature required only for religious exemption) Date
(.pdf) https://www.applyweb.com/apply/ugsgc/immunization.pdf

GEORGIA STATE UNIVERSITY
Georgia State University CERTIFICATE OF IMMUNIZATION (effective 6.21.2012)
health.gsu.edu/files/2013/03/2012_6_21_immunizationFormandInformation.pdf

Geogia State University
Form Six CERTIFICATE OF IMMUNIZATION 2005 / 2006 Form
PART III – EXEMPTIONS (bottom of Page 2)
Use AFFIDAVIT below, if asked for additional statement.
(.pdf) http://www.applyweb.com/apply/gsurcb/pdf/immunization.pdf

CERTIFICATE OF IMMUNIZATION
University System of Georgia
Religious Exemption bottom of page. Only a signature is required.
(.pdf) http://www.applyweb.com/apply/asu/immunization.pdf

GEORGIA COLLEGE & STATE UNIVERSITY
CERTIFICATE OF IMMUNIZATION
University System of Georgia
(.pdf) www.gcsu.edu/docs/Immunization_Certificate.pdf

University of West Georgia
Carrollton, Ga. 30118-4700
(.pdf) http://www.westga.edu/assetsDept/health/COI(6).pdf
Only a signature is required.

Kennesaw State University
Religious Exemption : I affirm that immunizations are in conflict with my religious beliefs. I understand that I may be subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
Sign at the bottom of page.
Signature (only if declaring religious exemption) ________________________ Date ______________
(.pdf) www.kennesaw.edu/iep/docs/Immunization%20Form.pdf

BAINBRIDGE COLLEGE
Sign at the bottom of page.
Religious Exemption Request. I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
Signature of Student __________________________________________________Date:_____________________
required if claiming religious exemption
(.pdf) Bainbridge_College/immunization_form.pdf

Gordon College - Barnesville, GA
*********************************************************************************************
     ϑ Religious Exemption
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
     ____________________________________________________________________________
                         Signature of student                                         Date
     (Student signature required only for religious exemption)

Board of Regents of the University System of Georgia
270 Washington Street, S.W., Atlanta, Georgia 30334
Exemption at bottom of page.
(.pdf) www.usg.edu/student_affairs/documents/coi-form.pdf

Georgia Southern University
Statesboro, GA 30460-8043
Part III – Religious Exemption - Put checkmark and PRINT name of student, only if claiming religious exemption.
Bottom of Page 2
(.pdf) http://services.georgiasouthern.edu/aux/pdf/health/CertificateofImmunizationForm.pdf

GAINESVILLE STATE COLLEGE
Religious Exemption at bottom of first page.
(.pdf) http://www.gsc.edu/admissions/Admissions Documents/Immunization Form.pdf

Armstrong Atlantic State University
11935 Abercorn Street, Savannah, Georgia 31419
Part III – Exemptions
Bottom of Page 2
(.pdf) www.armstrong.edu/images/admissions/immunizationform.pdf

Mercer University
RELIGIOUS EXEMPTION (Must be signed and notarized)
http://disclosure.mercer.edu/health/
Exemptions from compliance with the immunization policy include:
    Religious exemption, written on letterhead stationery, signed by a religious official and notarized.
    Medical exemption, written on office stationery, and signed by a health care provider. The letter should state the reason for the exemption, and whether the exemption is permanent or temporary.
[Note: Federal law stating that one does not have to be a member of a specific religion or denomination to hold a religious belief may over-ride the "signed by a religious official" above.]

Word Perfect Document (.wpd): Archived Copy of WPD document. Use for reference only.

Some colleges may ask for an additional statement to be attached.   For those other colleges and universities, you may use the AFFIDAVIT for Georgia Adult (college & employment religious exemption) below.

This AFFIDAVIT below is sufficient for a religious exemption statement from MMR and any other vaccines to post secondary institutions. Most colleges now have their mandatory waiver for meningitis. The required documentation informs the postsecondary school, and thus the state, that the student has either been vaccinated for meningococcal meningitis or has chosen to decline the vaccine.
This AFFIDAVIT letter will fit nicely on front and back paper.
AFFIDAVIT for Georgia Adult (college & employment religious exemption) ... Edit as needed...

AFFIDAVIT

I, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being, state Citizen of the Georgia 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, Georgia code, 1-4-13(a) and Georgia code 49-4-183(10)(C) 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 Georgia

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___



The Google searches belwo 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:

(.doc) VaccineTruth.net/letters/Immunization GA employment.doc

These forms read like the OSHA Hep B forms, but are covering the MMR/Smallpox Vaccines

Emory University
Vaccine Consent/Declination Form for all but Hep B
(.word) http://www.ehso.emory.edu/content-forms/NonHepBImmunizationReviewForm.dot

Emory University
Hep B Vaccine Consent/Declination Form
(.word) http://www.ehso.emory.edu/content-forms/HepatitisBImmunizationReview_DeclinationForm.dot

Return To: Immunization Coordinator
Environmental Health and Safety Office
Emory University, School of Medicine
1462 Clifton Road, Suite 300
Atlanta, GA 30322


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

Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

OptOutRegistry for Vaccines
and various other Opt-Outs
Vaccine Registry Opt-Outs:

Immunization Registry Opt Out: Forms

(.pdf) Opt-Out of Registry Form

(.pdf) Formulario para Solicitar la Baja del Registro (Opt-Out of Registry Form en Espanol)

     - - - - 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


Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

Employment
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

Click here for an Affidavit for Adult (college & employment religious exemption) ... Edit as needed...


Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

TB and/or Lead Testing

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/QuantiFERON_TB_Gold_testimony

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 QXCI-BioMeridian Providers, etc below

Click for the desired information for your state

New Born Issues: NewBornBirthingPlan&BirthExemptions  |   Waivers_CareInSigning  |   Letters_Forms_Affidavits
School-Daycare-Preschool Issues: Schools  |   DayCare  |   Preschool  |   K-12  |   College  |   (options) OptOutRegistry  |  
Adult Issues: Employment  |   TB_and/or_LeadTesting
Statutes/Laws  |   Waivers_CareInSigning  |   Misc_Info, Sponsors, etc.

Misc Info - Sponsors - Etc.
Here are some of the practitioners for Georgia

Georgia BEST™ BioMeridian Practitioners:

Quantum Healing Wellness Center
Dr. Jessica Rand, ND
2810 Peachtree Industrial Blvd. Suite D
Duluth, GA 30097
404-386-5468
http://qhwc.com
E-mail: QHWCDrJess@aol.com
Meridian Stress Assessment
Bio Energetic Stress Assessments & Electrodermal Screening
Immune Function and Pathogen Survey
Scan for signatures of bacteria, viruses, parasites, mold, fungi. Assess the main immune defense systems.

Healing Path, Inc.
Dr. Donna Donache
5025 Chartley Circle, SW, Lilburn, Georgia 30047
770.931.0123 (phone) 770.921-1758 (fax)
http://www.healingpathinc.com/html/naturopathic_assessment.html
http://www.healingpathinc.com
info@healingpathinc.com
IMMUNE FUNCTION/PATHOGEN SURVEY (1 HR.)
Scan signatures of bacteria, viruses, parasites, & fungi
. Assess the main immune defense systems: $100

CHRISTIAN HOLISTIC HEALTH CARE
Healthy Touch Whole Health Care

Howard J. Elrod RMT, NCTMB 504 Riverside Parkway, Suite 114
Rome, Georgia 30161
706-232-0708

Georgia QXCI Practitioners:

http://www.theqxci.com/information.php

Elaine Reedy
Visual Cell Biofeedback
1479 Brockett Rd. Suite #102
Tucker, GA 30084
770-270-0355

Peachtree Healing Arts
Lizbeth Widing
Atlanta, GA
678-438-0761

For information on purchase or lease of the new Quantum Life BioFeedback L.I.F.E. System, please email Donna at Exemptions Contact Page 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.
The L.I.F.E. System is also registered with the FDA for safety issues as a Class 2 Biofeedback Device.

Oxy-Powder