You can find your state legislative code to list on the exemption at this link.
Date Presented __________________
EXEMPTION OF VACCINATION AFFIDAVIT
In Accordance with The State of Ohio
Legislature, ORC Ann. 3313.671 (Anderson 2007)(B)(4) :
We, ___________________________________________ and ____________________________________________, sui juris, free, state Citizens of the State of Ohio
affirm: Be it known to all courts, governments, and other parties that:
It is against our deep, sincerely held, and philosophical conviction to accept the administration of a vaccine injection into the body of our daughter.
This is a written statement to exempt our child from any immunizations, TB testing, and other shots/injections, because we hold genuine and sincere personal philosophical beliefs which are inconsistent with these medical procedures. The practice of vaccination and the injection of any foreign substance are contrary to our conscientiously held values and practices, and violates the free exercise of our principles.
A conflict arises because our philosophical convictions are predicated on the belief that the introduction of destructive substances is inappropriate and an unsuitable way of sustaining health and wellbeing.
We, ___________________________________ and _________________________________, as the parents of _________________________________ are exercising our rights under the State of Ohio Legislature
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,
_______________________________________________________________,
Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.
_____________________________________________________________________________
Signature of Affiant
ACKNOWLEDGMENT
State of Ohio,
On this _______ day of ______________, 20___, 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 ______________________________, 20___