Dear Madam:

I hereby declare that, I, ______________________, as the custodial parent having responsibility for my child, _______________________, who is a minor child enrolled in the __________________________ School, withhold my consent on Tuberculosis screening for _______________________on the grounds that such testing is in violation of my United States of America constitutional 1st Amendment Right to religious freedom. It would be a violation of my religious beliefs to knowingly contaminate the body with inorganic and/or organic substances that can cause injury, illness, or other harm to human well-being.

I further assert the following:

_______________________ has not exhibited any of these of symptoms. There is no reason to suspect that she may be infected with Tuberculosis.

The Center for Disease Control further breaks down those who are more vulnerable to Tuberculosis as follows:

_______________________does not fall into any of these categories. The % chance that she may be infected with Tuberculosis is minute and thus, provides no basis to suspect that she may be infected with Tuberculosis.

I have included these assertions to show that _____________________ not being tested for Tuberculosis, poses no threat to the health and well-being of the student body at ________________________ School.



Notary Public:

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Signature                            Date

__________________________       _________________

City, State,               My Commission expires