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Vaccine Exemption Forms

In continuation of this year’s Vaccination Awareness Week – I want to present my personal exemption.

If your child is not going to be up-to-date on vaccinations by the time they reach pre-school, or if they will be attending group care, they will need some form of exemption on file for the state.

Here is a great link to find out more about your state laws and what exemptions are permitted. Our family chooses to implement a philosophical exemption.

(According to Vaccine Rights dot com, you should not copy an exemption letter from the internet because legally this is ‘insincere’ and could be a basis for rejection an exemption. Instead, please use mine as a reference and leave a comment if you have any questions!)  

Date Presented __________________


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 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 hold dispute over the safety, ethics and efficacy of vaccinations.

We, ____________________________ and _________________________, as the parents of __________________________ are exercising our rights under the State of Ohio Legislature, ORC Ann. 3313.671 (Anderson 2007)  (B) (4) to receive Religious/Philosophical Exemption from vaccination & testing.

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    


state of Ohio
county of _________________:
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___

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