An alternative approach and legal form can be found here.

Notice to agent is notice to principal

Notice to principal is notice to agent

As the parent of Sally Doe, I am prohibited by law from endangering my son or daughter; therefore, I declare the following: Sally Doe’s address: 2525 Maple Lane, Grove City, Ohio

1) I am aware that those ordering and/or administering vaccines have been granted immunity from liability should my son or daughter suffer from a vaccine-caused injury or illness. The Vaccine Injury Compensation Trust Fund is not an acceptable alternative to me. (Reason listed below – #10)

2) Unless I receive the vaccine manufacturer’s package inserts, I have not been given full disclosure regarding any vaccine. CDC or public health vaccine information sheets and/or websites are not acceptable alternatives. (Reason listed below – #4 & #5)

3) I am aware that vaccine schedules have been established by the CDC and are promoted by public health departments, the American Academy of Pediatrics and other organizations. I do not accept CDC recommendations as science-based. (Reason listed below – #4 & #6)

4) I do not recognize the CDC as a government health advocacy organization. It is a corporation listed on Dun and Bradstreet and headquartered in the STATE OF GEORGIA, with strong ties to the pharmaceutical industry. Therefore, their recommendations are influenced by the ‘fiscal’ health of their corporation.

5) I am aware that physician or institutional records are frequently reviewed by the HEALTH, OHIO DEPARTMENT OF, a corporation headquartered in COLUMBUS OH and listed on Dun and Bradstreet that receives monetary compensation from the CDC to perform this function. Therefore, the state public health department’s recommendations and actions are influenced by the ‘fiscal’ health of their own corporation.

6) I do not recognize the AMERICAN ACADEMY OF PEDIATRICS nor the AMERICAN ACADEMY OF FAMILY PHYSICIANS as health advocacy organizations. They are both corporations (listed on Dun and Bradstreet) that are head-quartered in the STATE OF ILLINOIS and the STATE OF KANSAS respectively, whose monetary compensation from the vaccine manufacturers contributes to the ‘fiscal’ health of their corporations.

7) I am aware that many physicians are paid higher reimbursement rates for administering vaccines.

8) I am aware that LEGISLATORS for the corporation known as the STATE OF OHIO, listed on Dun and Bradstreet, vote on statutes for the STATE OF OHIO. These include statutes mandating certain vaccines for attendance in educational institutions. As the LEGISLATORS have no medical training and can easily be influenced by drug company lobbyists and/or the CDC, I do not accept their mandates as science-based. To the best of my knowledge, I have signed no contract with these LEGISLATORS. Therefore, their corporate vaccine statutes do not apply to me or my son or daughter unless I consent to abide by them.

9) I am aware of multiple scientific peer-reviewed papers that have exposed the dangers of many vaccines as well as the “herd immunity myth” of 1933.

10) I am aware that the corporation HEALTH & HUMAN SERVICES, UNITED STATES DEPARTMENT OF (listed on Dun and Bradstreet and headquartered in WASHINGTON DC) determines claims paid from the Vaccine Injury Compensation Trust Fund via a secret administrative procedure and also profits from vaccine patents.

11) I have concluded that failure to follow CDC vaccine recommendations is less likely to endanger the health of my child or others than following their recommendations.

As parent or guardian I am prohibited by law to endanger my child. So, for the reasons I have listed and more, I deny permission for anyone to administer CDC recommended vaccines to my son or daughter unless they provide me with the vaccine package insert, allow me to determine if the health risks are acceptable, and sign a document stating that they personally, not me, (and/or my spouse) will be responsible for any injury or illness (as defined by the International Medical Council on Vaccination) the vaccine they administer might cause.

NOTE: This document can be used to protect those that administer vaccines (physicians, nurses or others) or are obliged to adhere to corporate statutes (including educational institutions) from any punitive statutory actions or penalties.

Parent/Guardian: Jane Doe Signature: ___________________ Date: ______

Parent/Guardian: John Doe Signature: ___________________ Date: ______

Witness: Richard Smith    Signature: ___________________ Date: ______

Witness: Anna Thomas     Signature: ___________________ Date: ______

This form in easily printable version: Vaccination Notice Template 6-17-14