What I’m referring to is the
sudden influx of some state exemption/waiver forms that use deliberate trickery in the language to
catch unsuspecting parents off guard. It is modeled after the American
Academy of Pediatrics "Refusal
To Vaccinate" form.
Lately, we have seen a sudden rise
in these types of forms. The question is
Are any of you aware of this
form? If not, please continue reading. Please check your state statute if
ever asked to use these forms. Insist they show you where it’s required.
endorsing this particular waiver, parents would essentially be signing an
admittance of neglect and or "abuse" for refusing vaccines. The
language contained in this waiver could put parents and caregivers in jeopardy
down-the-line if they should ever find themselves in the courts due to their
child's health problems, when confronted with child protective services,
divorce, or just about any matter pertaining to that child that could be used
against the parent(s)”. ~Anai Rhoades Ford
Why Signing a
Waiver to Avoid Vaccines Can Be Considered Abuse by Anai Rhoads Ford. http://www.anairhoads.org/medical/saynotovaccines.shtml
Parents and caregivers Beware!
Some states have it in their state
exemption statutes such as Arkansas in
order to obtain the exemptions. http://www.vaclib.org/exempt/arkansas.htm
We took the “Refusal To Vaccinate” form and modified it to keep parents safe
For help and local support in Arkansas contact:
Waldron, Arkansas 72958
Email Address: firstname.lastname@example.org
Other states such as Idaho and Tennessee are not required by law to use this form.
Here’s what was found in Tennessee:
Religious Exemptions may be
granted to a student whose parent/guardian files with the school a Vaccination(s)
Refusal Due To Personal Religious Beliefs document.
Note: This form must be signed by a Notary Public.
Actual form: http://kcs2.knox.k12tn.net/kcsforms/AD/AD-H-337.pdf
Also in Rutherford County Schools
(only the information about it is mentioned)
These forms need to be edited by
crossing some things out.
Idaho has a similar form as well, but it is not required by law. I.C. § 39-4804
See how we edited the Idaho state form Idaho’s page. http://www.vaclib.org/exempt/idaho.htm
Here are examples of deliberate trickery in the wording of
this State of Idaho forms:
Be sure to cross out ALL the “nots” if you are asked to use these forms.
Page 1 of the form...
Please read the following statements and initial each statement
regarding vaccine preventable diseases for which an exemption is being claimed.
Diphtheria: I understand by
receiving the Diphtheria vaccine, my child is at risk of developing a sore
throat, low-grade fever, heart complications, paralysis, respiratory
complications, coma and even death.
Tetanus: I understand by
receiving the Tetanus vaccine, my child is at risk of developing seizures and
possible fatal neuromuscular disease.
Pertussis (Whooping Cough): I understand by
not receiving the Pertussis vaccine, my child is at risk of
developing pneumonia, seizures, inflammation of the brain, neurological
complications and even death.
Polio: I understand by
receiving the Polio vaccine, my child is at risk of developing a fever, sore
throat, nausea, headaches, stomachaches, stiffness, and paralysis that can lead
to permanent disability and death.
Measles: I understand by
receiving the Measles vaccine, my child is at risk of developing a rash, high
fever, cough, runny nose, red, watery eyes, diarrhea, ear infections, pneumonia,
encephalitis, seizures, and death.
Mumps: I understand by
receiving the Mumps vaccine, my child is at risk of developing a fever,
headache, muscle aches, swelling of the lymph nodes close to the jaw,
meningitis, inflammation of the testicles or ovaries, sterility, arthritis,
inflammation of the pancreas and deafness (usually permanent).
Rubella (German Measles) I understand by
receiving the Rubella vaccine, my child is at risk of developing a rash and
fever in children and young adults, birth defects if acquired while pregnant
include deafness, cataracts, heart defects, mental retardation, and liver and
Hepatitis B: I understand by
receiving the Hepatitis B vaccine, my child is at risk of developing yellow
skin or eyes, tiredness, stomachaches, loss of appetite, nausea, or joint pain,
life-long liver problems, such as scarring of the liver and liver cancer.
More deliberate trickery of the wording on Page 2:
"I know that
failure to follow the recommendations about vaccination may endanger the health
or life of my child and others that my child might come in contact with. I
acknowledge that I have read this document in its entirety and fully understand
You could alter the form and say:
"I know that
follow(ing) the recommendations about
vaccination may endanger the health or life of my child and others that my
child might come in contact with. I acknowledge that I have read this document
in its entirety and fully understand it."
"RELIGIOUS or PERSONAL STATEMENT: I have investigated the risks of
not vaccinating my child; nevertheless (therefore) I have decided to not
vaccinate my child for the following reason(s):"
(You may attach one of our Vaccination
Liberation Idaho Exemption Forms, or simply cite I.C. §
Please be aware that not all state issued exemption/waiver
forms contain this deliberate trickery in the language. Write your own forms, if the state statute
allows it and use our ACCEPTANCE OF
RESPONSIBILITY form. http://www.vaclib.org/legal/accept1.htm
This is a SAFE form you can use that we modified:
This is the UNSAFE form that you should NEVER
See the differences?
Donna Carrillo, co-director
"Ask me about vaccine exemptions"