I,____________________________, as the parent, guardian or person in

(insert your name)
loco parentis of the child __________________________ after considering the
(insert child’s name)
risks and benefits of the vaccine(s) do hereby decide not to vaccinate my child with the following vaccines:

Diphtheria ◻ Tetanus ◻ Pertussis ◻ Polio

Measles ◻ Mumps ◻ Rubella ◻ Varicella

Influenza Meningococcal Pneumococcal Rotavirus

Hepatitis B Hepatitis A Haemophilus influenzae type b

Human Papillomavirus Other_________

This is pursuant to my right to refuse vaccination on the statutory grounds of “other grounds”. This statement is for my child's files and can be shown to the school administrator or operator of the group program pursuant to I.C. § 39-4804.

Date: ____________________       __________________________

Parent/Guardian or Person in loco parentis

  39-4804.  Notification to parent or guardian. (1) Before an immunization is administered to any child in this state, the parent or guardian of the child shall be notified that:
(a)  Immunizations are not mandatory and may be refused on religious or other grounds;
(b)  Participation in the immunization registry is voluntary;
(c)  The parent or guardian is entitled to an accurate explanation of the complications known to follow such immunization.
(2)  At the time information is initially collected regarding any child for entry into the registry created pursuant to this chapter, the parent or guardian shall be notified that:
(a)  They have the right under Idaho law to submit a statement pursuant to the provisions of sections 39-1118 and 39-4802, Idaho Code, which exempts them from any requirement to have information regarding the child entered into the registry;
(b)  At any time they have the right to remove any information from the registry regarding the child; and
(c)  Immunizations are not mandatory and may be refused on religious or other grounds.
(3)  The decision of a parent or guardian to:
(a)  Submit a statement pursuant to the provisions of either section 39-1118(2) or 39-4802(2), Idaho Code;
(b)  Remove any information regarding the child from the registry pursuant to the provisions of section 39-4803(4), Idaho Code; or
(c)  Refuse the immunization on religious or other grounds;
shall not be used in any manner against the interests of the parent or guardian in any administrative, civil or criminal action.
39-4802.Exemptions. (1) Any minor child whose parent or guardian has submitted to school officials a certificate signed by a physician licensed by the state board of medicine stating that the physical condition of the child is such that all or any of the required immunizations would endanger the life or health of the child shall be exempt from the provisions of this chapter.
(2) Any minor child whose parent or guardian has submitted a signed statement to school officials stating their objections on religious or other grounds shall be exempt from the provisions of this chapter.

The term “or other grounds” means that, as the parent and legal guardian, I have the right to choose whether or not to vaccinate my child. The statute does not require that I disclose what other grounds our refusal to immunization is. As with any medical decision, the decision to vaccinate or not is a right of the individual or parent. The state of Idaho, our doctor and public health employees cannot force my child to be vaccinated. My child cannot be excluded from a school or public program because we have exercised our right to not vaccinate.

Making Informed Decisions
Your decision to vaccinate or not should be an informed decision. Vaccines can cause severe injuries such as seizures, death, anaphylaxis, brain damage and other reactions. The type and severity of reactions may vary from vaccine to vaccine and child to child. The effects of a vaccine injury may be temporary or permanent. If you notice any changes in your child’s condition after receiving a vaccine, you should contact your doctor immediately or go to a hospital. Vaccines have never been proven to be safe or effective and your child may contract the disease even if he is vaccinated. What has been proven is that you can get the disease from the vaccine or from coming into contact with a recently vaccinated person. The polio vaccine is just one example. It is a known fact that most healthcare providers do not fully inform patients of the side effects a vaccine can have on the body, brain and immune system. Because of the highly toxic ingredients all vaccines contain, you should thoroughly research vaccines for yourself before making such an important decision. DO NOT allow someone else, even your healthcare provider, scare or force you into making this decision without being fully informed. Many healthcare providers have not researched vaccine history or toxicology and are not fully informed.

Always provide a detailed history of your child’s health to your doctor. Make sure they know of allergies, neurological problems, nutritional deficiencies, any immune system disorder and skin diseases such as eczema. Most physicians and nurses do not warn parents that if their child’s health is compromised in any way, such as having a common cold or previous reaction to a vaccine, they should not receive vaccines.

Benefits of Non-Vaccination
When you choose to not vaccinate your child, you have the responsibility to educate yourself on how to maintain the well-being of not only their body but also their mind and spirit as well. Childhood diseases can result in minor symptoms to severe complication or death depending on the child’s immune system and treatment protocols followed. The stronger the immune system, the less severe are the symptoms of the disease. A child that goes through the full expression of the disease (i.e. fever and skin eruptions, without suppressing any of these symptoms) usually acquires immunity from that disease for life. Good nutrition and cleanliness play a major role. The risk of contracting various diseases can vary over time or locality. Symptoms or complications of these diseases may be treatable by alternative methods or may resolve without treatment. Educate yourself on childhood diseases from informed alternative sources. Fear of these diseases comes from not being properly informed.

For More Information
To make a truly informed decision there are numerous sources of information on the risks of vaccines and the risks and benefits of childhood diseases. Sources of information to determine if the risks associated with vaccines outweigh any perceived benefits include: vaccine package inserts, the Physicians Desk Reference, the U.S. Center for Disease Control and Prevention, public and medical libraries or state and local health agencies. (NOTE: These sources do not give complete and total information on vaccine ingredients and their toxicity, nor do they provide accurate statistics.)

Vaccination Liberation – or (888) 249-1421

National Vaccine Information Center – or (703) 938-0342

(NOTE: The two websites above, Vaccination Liberation and the National Vaccine Information Center, have proven to be excellent sources for extensive vaccine information.)

Reporting Reactions
If you do decide to vaccinate, report vaccine reactions to the Vaccine Adverse Event Reporting System by going to Always get the vaccine name, vaccine manufacturer and lot number. Keep records of day to day reactions from the time of vaccination for at least 6 months to 2 years, no matter how slight the reactions. Long-term effects of vaccines have not been well documented by the allopathic community and are just now being researched. If your child has been injured by a vaccine, he may be eligible for compensation under the National Vaccine Injury Compensation Program.

Revised 5/11     Source: Vaccination Liberation, P.O. Box 235, Hayden, ID 83835-0235     CopyRound ©

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