Fill and Sign the Affidavit Waiver Form

Affidavit for Waiver of Vaccination of Child due to Religious Convictions STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ___________________ (Name of Affiant) , who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. I am the ______________________ (Mother and/or Father or Guardian) of _________________ (name of child) , hereinafter called Child . 2. I t is against my deep and sincerely held religious convictions to accept the injection of any foreign substance into my body or the body of my Child. This includes, but is not limited to, any and all, vaccinations, shots, tests for diseases, oral vaccines, epidermal patches and/or in any other procedure where live or dead bacterium, viruses, pathogens, germs, or any other microorganisms, may be introduced into or upon my or my newborn Child’s body. 3. This Affidavit is being made to exempt my newborn Child from any i mmunizations , newborn screening , and the Vitamin K shot , because I hold genuine and sincere personal religious beliefs which are inconsistent with these medical procedures. The practice of vaccination and the injection or application of any foreign substance is contrary to my deeply held religious beliefs and practices, and violates the free exercise of my religious principles. ____________________________ (Printed Name of Affiant) ___________________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____. __________________________ NOTARY PUBLIC My Commission Expires: ___________________