TENNESSEE - IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)
IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)Tennessee
Current Statutes & Laws: http://www.nvic.org/Vaccine-Laws/state-vaccine-requirements/tennessee.aspx
Medical & Religious
Requirements do not apply to any "child whose parent or guardian files with proper authorities a signed, written statement that such immunization and other preventative measures conflict with the religious tenets and practices of the parent or guardian affirmed under penalties of perjury."
PDF documents (.pdf)
A special reader, Acrobat Reader software for Windows(TM), Macintosh(TM), MS-DOS(TM), SGI(TM), and Sun(TM) is required and is available free from Adobe.
Download Acrobat Reader:
Exemption Letters & Forms...
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.
IMPORTANT! Please download this if you're expecting a child or know someone who is!
This proves to the hospital that religious exemption is allowed for newborn screening in Tennessee.
Metabolic/Genetic Newborn Screening Program In Tennessee
Refusal Form Page 27 of the pdf file
(.pdf) http://www2.state.tn.us/health/Downloads/4%20NBS.pdf
XI. Refusal to Have Newborn Screening Performed
When a parent refuses the newborn screening test, we ask that you do send in a newborn screening collection form completely filled in and write “REFUSED” on the form, and we will follow up. If a parent refuses the test due to religious reasons, please fill out the NEWBORN SCREENING REFUSAL FORM
(See Page IV - 25), have it notarized, and fax it to Maternal and Child Health at (615) 262-6458.
Vitamin K Injection...
The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert.
(.pdf) http://vaclib.org/chapter/inserts.htm#vitK"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."The package insert should be printed out and used along with the birth plan letter, the Newborn Screening Refusal form on page 27 of the manual (above...), and your exemption letter or AFFIDAVIT. This shows the hospital or birthing center that you are aware of the risks of Vitamin K injection, and that they should be too.
fatalities=death
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
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.
Sample Vaccine Letters From this website... Archived: http://www.vaccines.bizland.com/letters.htm
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.
(Links to model birth plan letter and acceptance of responsibility)
Acceptance of Responsibility. http://www.vaclib.org/legal/accept1.htm
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...
(.doc) Model Letter for Hospital Births (Model11425.doc) Model Birth Plan Letter for Hospital Births. This one is more detailed. You can attach an exemption from immunizations. In some states, there are religious exemptions from newborn screening tests such as PKU, etc...
(.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)
(.doc) VaccineTruth.net/letters/Model letter for hospital births for adoptions.doc
The above documents can also be made available in WordPerfect 
(.wpd) format.
Please contact us if you want the model birth plan letters in WordPerfect.
Information on the Dangers of Hospital Birth and the Benefits of Home Birth
Our best and most itemized birthplan:
(.doc) birthplan-itemized.doc |
(.pdf) birthplan-itemized.pdf
(HTML) BirthPlan-Itemized for reading on screen. Includes handy small dictionary of terms in the document.
The birth plan arrangements and letter should be turned in before delievery date.
This "Refusal to Permit Medical Treatment" form is optional to use.
"Refusal to Permit Medical Treatment" form
Refusal to Permit Medical Treatment. A generic form.
(.pdf) ../letters/refusal_treatment.pdf
It would be good idea to use with the AFFIDAVIT below AND model birth plan letter. We hope someone uses this affidavit, model birth plan letter and refusal forms, and succeeds. We want to hear about it when someone is successful with this. 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!
Birth plan religious AFFIDAVIT text below. Use with model birth plan letter and/or refusal forms, and edit as needed...
AFFIDAVIT available in Microsoft Word (.doc) and WordPerfect (.wpd) format.
AFFIDAVIT
I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of the Pennsylvania Republic affirm: Be it known to all courts, governments, and other parties that:
Being (a person/people) of Strong Christian Morals, it is against (my/our) Deep, Sincerely Held, Religious Convictions to accept the injection of any foreign substance into (my Body/our Bodies) or the Body of (my/our) Child. 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/our) newborn's body.
This written statement to exempt (my/our) newborn from any immunizations, newborn screening, and the Vitamin K shot, because (Iwe) hold genuine and sincere personal religious beliefs which are inconsistent with these medical procedures & experimentation. The practice of vaccination and the injection or application of any foreign substance is contrary to (my/our) conscientiously held religious beliefs and practices, and violates the free exercise of (my/our) religious principles.
The Hepatitis-B vaccine supposedly protects against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps (my/our) parental authority to condemn such activity in (my/our) child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of (my/our) faith.
The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert.
http://vaclib.org/chapter/inserts.htm#vitK
"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."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 injection of carcinogenic substances that can kill.
(We / I) {First and Last name(s)}, as the {(parent (s) / guardian(s)} of ______________________(name of newborn child) are exercising (our/my) rights under the First Amendment of the US Constitution and Tennessee Statutes TCA 49-6-5001 (b)(2) to receive Religious Exemption from Vaccination, ALL injections, & 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/our bodies) and that of (my/our) family that (I/we) can accept.
(I/We) affirm that vaccination & injections of any foreign substances and proteins conflict with (my/our) religious beliefs as stated above. Therefore, (I/we) would request that you accommodate (my/our) religious beliefs and practices by exempting (my/our) newborn child from any vaccinations, injections and testing of any kind.
Rest assured that (my family and I/our family) do practice a form of immunization that keeps our immune systems 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 Tennessee
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 above AFFIDAVIT is available in Microsoft Word
(.doc) and WordPerfect (.wpd) format.Click here to Contact Donna.
Postnatal - 2 months (first "well baby" visit):
If you do take your new baby to an MD as opposed to a naturopath and/or chiropractor, please be aware and careful of any forms you sign.
We're referring to those "Refusal To Vaccinate" forms put out by the American Academy of Pediatrics. Go to this page below and find out why signing this form is very dangerous. We all know about these forms and how they can be used to undermine parental rights...
http://www.vaclib.org/legal/donotsign.htm
State Form Required: Yes. TCA 49-6-5001(b)(2) Green Official TN Certificate of Religious Exemption. However, some schools have accepted letters from parents, and some schools have their own exemption form.
"By 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).
Please read any waiver provided by your child's doctor carefully before signing. Instead, offer a formally written and signed letter that simply says that you do not wish to vaccinate your child. If you are unsure of the language in the waiver, buy some time by telling your doctor that you need to consult with a lawyer before signing it. "
Anai Rhoads Ford
Human Rights Journalist
Why Signing a Waiver to Avoid Vaccines Can Be Considered Abuse by Anai Rhoads Ford, released 15 November 2005.
http://www.anairhoads.org/
Media Contact (703) 491-1903
STATE OF TENNESSEE DEPARTMENT OF EDUCATION / Model Form Religious Exemption from Vaccination(s) ED-5379 http://tennessee.gov/education/schoolhealth/healthservices/doc/ReligiousExemptionFormED-5379.pdf
Tennessee Immunization Requirements
http://www.christianuc.com/vax/law/tennessee.php
Daycare & Preschools:
AFFIDAVIT for Tennessee Older Child below...
Can be used for daycare, preschools and schools, edit as needed.
AFFIDAVIT
I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of the Pennsylvania 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 or the Body of my Children. 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 or any of my children’s bodies.
This written statement to exempt my child from any immunizations, TB testing, and other shots/injections, 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 and therefore usurps my parental authority to condemn such activity in my child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of our faith.
(We / I) {First and Last name(s)}, as the {(parent (s) / guardian(s)}of _________________________(name of child) are/am exercising our rights under the First Amendment of the US Constitution and Tennessee Statutes TCA 49-6-5001 (b)(2) to receive Religious Exemption from Vaccination.
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.
Our Creator Yahweh and the Lord Jesus Christ is the only source of protection of my body and that of my family that I can accept.
I affirm that vaccination & injections of any foreign substances and proteins conflict with my religious beliefs as stated above. Therefore, I would request that you accommodate my religious beliefs and practices by exempting my child from any vaccination or injections of any kind.
Rest assured that my family and I do practice a form of immunization that keeps our immune systems 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 Tennessee
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___
Schools:
Religious Exemption Letter. In some districts, you may be required to get the Official Tennessee Certificate of Religious Exemption. It's a green form. However,you may use this letter to give the health dept to obtain the green form, if necessary.
Tennessee religious exemption letter.doc (5226)
VaccineTruth.net/letters/Tennessee religious exemption letter.doc
HAMBLEN COUNTY SCHOOLS - Morristown, Tennessee
REQUEST FOR EXEMPTION FROM IMMUNIZATION
http://www.hcboe.net/main/Dept/director/forms/immunization_exmpt_JGCB.pdf
The following schools accept the HAMBLEN COUNTY SCHOOLS REQUEST FOR EXEMPTION FROM IMMUNIZATION form. All Elementary, Middle, High and Charter Schools in District listed below.
Hamblen County School District
210 East Morris Boulevard
Morristown, TN 37813
Elementary Schools
Alpha Elementary School
5620 Us 11e Hwy, Morristown, TN 37814
Fairview Marguerite Elementary School
2125 Fairview Rd, Morristown, TN 37814
Hamblen County Alternative School
376 Synder Rd, Morristown, TN 37813
Hillcrest Elementary School
407 S Liberty Hill Rd, Morristown, TN 37813
John Hay Elementary School
501 Brittain Court, Morristown, TN 37814
Lincoln Heights Elementary School
215 Lincoln Av, Morristown, TN 37813
Lincoln Heights Presch Center
217 Lincoln Av, Morristown, TN 37813
Manley Elementary School
551 West Economy Rd, Morristown, TN 37814
Russellville Elementary School
5655 Old Russellville Pk, Russellville, TN 37860
Union Heights Elementary School
3366 Enka Hwy. Morristown, TN 37813
West Elementary School
235 W Converse, Morristown, TN 37814
Whitesburg Elementary School
7859 East Andrew Johnson, Whitesburg, TN 37891
Witt Elementary School
4650 South Davy Crockett, Morristown, TN 37813
Middle Schools
East Ridge Middle School
6595 St. Clair Rd, Whitesburg, TN 37891
Hamblen County Alternative School
376 Synder Rd, Morristown, TN 37813
Lincoln Heights Middle School
219 Lincoln Av, Morristown, TN 37813
Meadowview Middle School
1623 Meadowview Ln, Morristown, TN 37814
West View Middle School
One Indian Path, Morristown, TN 37813
High Schools
Hamblen County Adult High School
210 E Morris Bl, Morristown, TN 37813
Hamblen County Alternative School
376 Synder Rd, Morristown, TN 37813
Morristown High East
One Hurricane La, Morristown, TN 37813
Morristown High West
1025 Sulphur Springs Rd, Morristown, TN 37813
Other Hamblen County school forms: http://www.hcboe.net/main/Dept/director/forms/contents.htm
Opt-Outs:
Military Recruiters:
STUDENT OPT OUT FORM regarding the
RELEASE OF NAME, ADDRESS, AND TELEPHONE NUMBER TO MILITARY RECRUITERS
(.pdf) http://www.militaryfreeschools.org/PDF/optout2.pdfUNDERGROUND ACTION ALLIANCE STUDENT OPT OUT FORM
(.pdf) http://www.militaryfreezone.org/opt_out.pdf (.doc) http://veterans4peace.org/opt_out.docSAMPLE ENGLISH - BINGUAL FORMS FOR OPTING OUT
Act to Protect Your Privacy from Military Recruiters
(.pdf) http://www.afsc.org/pacificsw/documents/Opt-Out-Form.pdf 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) http://www.ccv.org/images/StudentOptOutNotice.PDF (.pdf) http://www.catholiccitizens.org/content/img/f26422/opt%20out%20notice.pdf
(.html) http://www.ccv.org/images/StudentOptOutNotice.htm
Entire packet...
(.doc) http://www.mfc.org/respect/Website/Links%20on%20Web%20Page/Opt-Out%20Packet.docSTUDENT OPT-OUT NOTICE - Google Search
Colleges:
Links to University of Tennessee personal and religious exemptions:
University of Tennessee
Religious Exemption to MMR vaccine
(.pdf) http://web.archive.org/web/20040514145956/http://utc.edu/Administration/StudentHealthServices/re.pdf University of Tennessee
Personal or Religious Exemption to MMR vaccine
(.pdf)
http://web.archive.org/web/20060516175806/www.utcpolyclinic.com/re.pdf
East Tennessee State University
Religious Exemption Form:
(.pdf)
http://www.etsu.edu/nursing/shserv/documents/MMR_RELIGIOUS_EXEMPTION.pdfMeningococcal Meningitis and Hepatitis B
Immunization Health History Form
Has a check off for waiver
Hepatitis B/Meningitis Waiver (PDF)
(.pdf)
http://www.etsu.edu/nursing/shserv/documents/Hep_B_Waiver.pdf Hepatitis B/Meningitis Waiver (Word Doc)
(.doc)
http://www.etsu.edu/nursing/shserv/documents/Hep_B_Waiver.doc Tennessee State University
Student Health Services
Meningococcal Meningitis and Hepatitis B/Immunization Health History Form
(.pdf)
http://www.tnstate.edu/uploads/documents/MeningococcalMSrm(4-year).pdfFor other vaccine exemptions, check off appropriate section of Certificate of Immunization and attach statement.
(.pdf)
CERTIFICATE OF IMMUNIZATION__________________________________________________________
3. ϑ Refused immunization because of religious objections. Attach statement.
You may use the AFFIDAVIT for Tennessee Adult (college religious exemption) below.
Jackson State Community College
2046 North Parkway, Jackson, TN 38301 • (731) 424-3520 • (800) 355-5722
Hepatitis B Vaccine Health History & WAIVER
(.pdf)
http://www.jscc.edu/uploads/Admissions/hepatitis-B.pdf
Volunteer State Community College
1480 Nashville Pike
Gallatin, TN 37066
Hepatitis B Vaccine Waiver
(.pdf) http://web.archive.org/web/20070723175456/http://www.volstate.edu/Healthsvc/employee/hepB-Waiver.pdf
Vanderbilt University:
Student Health Center | Vanderbilt University
Zerfoss Building, MCN | 1161 21st Ave. S. | Nashville, TN 37232
Hepatitis B Vaccine Waiver Forms.
http://www.vanderbilt.edu/student_health/templatehb.html
Click on your school for appropriate form.
All Undergraduates.
(.pdf) http://www.vanderbilt.edu/student_health/04forms/hepBwaiver04.pdf
(.pdf) Hearing & Speech. http://www.vanderbilt.edu/student_health/04forms/hepB_HE.pdf (.pdf) Medical School. http://www.vanderbilt.edu/student_health/04forms/hepB_MED.pdf (.pdf) Divinity School. http://www.vanderbilt.edu/student_health/04forms/hepB_D.pdf (.pdf) Graduate School. http://www.vanderbilt.edu/student_health/04forms/hepB_US.pdf (.pdf) Law School. http://www.vanderbilt.edu/student_health/04forms/hepB_L.pdf (.pdf) Owen School. http://www.vanderbilt.edu/student_health/04forms/hepB_O.pdf (.pdf) Peabody College. http://www.vanderbilt.edu/student_health/04forms/hepB_CP.pdfMeningitis Vaccine Waiver Form.
http://www.vanderbilt.edu/student_health/templatemening.html
Click on your school for appropriate form.
All Undergraduates.
(.pdf) http://www.vanderbilt.edu/student_health/04forms/Mening_Vaccwaiver04.pdf (.pdf) Hearing & Speech. http://www.vanderbilt.edu/student_health/04forms/men_HE.pdf (.pdf) Medical School. http://www.vanderbilt.edu/student_health/04forms/men_MED.pdf (.pdf) Divinity School. http://www.vanderbilt.edu/student_health/04forms/men_D.pdf (.pdf) Graduate School. http://www.vanderbilt.edu/student_health/04forms/men_US.pdf (.pdf) Law School. http://www.vanderbilt.edu/student_health/04forms/men_L.pdf (.pdf) Owen School. http://www.vanderbilt.edu/student_health/04forms/men_O.pdf (.pdf) Peabody College. http://www.vanderbilt.edu/student_health/04forms/men_CP.pdfCumberland University Vaccine Wavier Form
Lebanon, TN 37087-3408
Hep B/Meningococcal Vaccine Waiver Form
(.pdf) http://www.cumberland.edu/admissions/events/VaccineForm2005.pdfAFFIDAVIT for Tennessee Adult (college 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 and TCA Section 49-6-5001 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 Tennessee
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___
These Google searches 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:
The University of Memphis
Memphis, TN 38152
HBV VACCINATION DECLARATION OF REFUSAL (employees)
(.pdf) http://www.people.memphis.edu/~ehas/HBVdecForm.pdfYou may use the AFFIDAVIT for Tennessee Adult above, leave out college code & edit as needed...
You would still use the OSHA Hepatitis B declination form for Hepatitis B vaccine.
Most of these are the Hepatitis B vaccine declination forms, such as the OSHA form. There are hundreds of these forms. Rather than linking to each one, here are the Google Search results for these keywords. There are other vaccines that one can decline that are worded like the OSHA forms.
Vaccine Declination Form
or
Hep B vaccine waiver
TB Test:
ADMISSION OF NON-CITIZENS
All children not born in the United States entering the Murfreesboro City Schools for the first time are required to present evidence of freedom from infectious tuberculosis. The evidence should include a report of a negative tuberculin skin test done in the United States, or if the skin test is positive, a chest X-ray or other necessary examinations to certify absence of clinical tuberculosis.
____________________
Legal References:
T.C.A. 49-6-3008(b)
TRR/MS 0520-1-3-.08(2)(a)
T.C.A. 49-6-5001(c)
T.C.A. 49-6-5102
T.C.A. 49-6-3051
TB Testing Exemption Letter:
HTMLSample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBwaiverGen.htm
Microsoft Word Document (.doc)Sample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBwaiverGen.doc
TB Testing Exemption Letter for Adults:
Microsoft Word Document (.doc)Sample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBTestingWaiverAdult.doc
WordPerfect Document (.wpd)Sample Exemption Letter for TB testing. May be modified to your use. http://www.vaclib.org/letters/TBTestingWaiverAdult.wpd
PDF document (.pdf)Sample Exemption Letter for TB testing. http://www.vaclib.org/letters/TBTestingWaiverAdult.pdf
Lead Testing Exemption Letter:
HTMLSample Exemption Letter for Lead testing. May be modified to your use. http://www.vaclib.org/letters/Lead_testing_waiverGen.htm
Microsoft Word Document (.doc)Sample Exemption Letter for Lead testing. May be modified to your use. http://www.vaclib.org/letters/Lead_testing_waiverGen.doc
The above TB and Lead exemption letters courtesy of Deirdre DeVane of Wash DC. Thank you Deirdre!
The adult TB letters were edited by Sherri Tenpenny. Thank you Sherri!
TB Testing Alternatives...
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.
Here are some of the practitioners for Tennessee
Tennessee BEST™ BioMeridian Practitioners:
Mind-Body Medical Center
Stephen L. Reisman, MD
2325 Crestmoor Rd. Suite P150
Nashville, TN 37215
Telephone 615-298-2820
Fax 615-298-2770
Offers a holistic approach to healing including nutrition—uses meridian stress assessment to check for energy imbalances in body.
Health & Stress Management Inc.
Dr. Eddi Boyd, RN, ND, PhD.
6949 Charlotte Pike, Suite 204
Nashville TN, 37209
(615) 356 - 5060
http://www.healthandstressmanagement.com
E-Mail: dreddiboyd@comcast.net
Meridian Stress Assessment
I utilize this bio-energetic technique in my office. It uses acupressure points on the body and using a computerized analysis, giving a very accurate and detailed print-out on your own bodies imbalances including; food, airborne intolerances, vitamin-mineral deficiencies, hormonal imbalances, chemical substitutes, organ and system stresses, weaknesses, etc.
South Wellness Center
Dr. Keith South & Lisa South RN BNS
Bio-Meridian Stress Assessment
Executive Park Building
4721 Trousdale Drive Suite 130
Nashville, TN 37220
Office Phone (615) 662-6500
Office Fax (615) 333-3147
http://www.southwellness.com/
drsouth@southwellness.com - For Dr. South
lisa@southwellness.com - For Lisa
melina@southwellness.com - For Melina
Meridian Stress Assessment
Kim Hanson (901) 755-8082
Terry Hanson, DC, (901) 757-9000
2121 Germantown Rd, S., #4
Germantown, TN 38138
NUTRITIONAL THERAPY
Mind-Body Medical Center
Stephen L. Reisman, MD
2325 Crestmoor Rd. Suite P150
Nashville, TN 37215
Telephone 615-298-2820
Fax 615-298-2770
Offers a holistic approach to healing including nutrition—uses meridian stress assessment to check for energy imbalances in body.
Tennessee QXCI Practitioners:
Mary J. Clement, Ph.D., JD/MSW
696B Northup Rd.
Portland, TN 37148 615-206-1553
mjclement@team-national.com
Web Address: www.bold-eagle.com
John Cole or Sharon Parker
105 Pembroke Court
White House, TN 37188
615-661-3956
john@tnbiohealth.com
sharon@tnbiohealth.com
Highland Realm
Deanna Naddy DSN, RN
4411 Hamshire Pike
Hamshire, TN, 68401
931-285-2543
or
229 Warv Circle Suite B-12
Brentwood, TN 32027
615-377-6767
drnaddy@earthlink.net
Web Address: www.highlandrealm.org
http://www.qxciscio.com/qxci-tennessee-tn.html
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 1-888-249-1421.
The L.I.F.E. System is also registered with the FDA for safety issues as a Class 2 Biofeedback Device
P O BOX 70984
Knoxville TN 37938
Kelly Riggs, director
1-865-556-7345 cell
1-865-922-1420 fax
kriggs2002@comcast.net