DO NOT SIGN the Refusal to Vaccinate form!


By AL Whitney © copyround 2015
Permission is granted for redistribution if linked to original and Parents Against Mandatory Vaccines is acknowledged.


The Refusal to Vaccinate document was created by the CDC or the American Academy of Pediatrics ‘legal department’ as a response to the growing number of toxic vaccines recommended by them and the growing number of parents who are becoming educated on this issue. According to CDC recommendations, our children should now receive 37 doses of vaccines between 0-16 years. [See Vaccine Schedule]

This document, now being used to overcome vaccine awareness, is the most diabolical strategy possible! It is unlikely that physicians have any idea what they are asking their patients to sign . . . or to sign away. It is essentially a signed confession. So please read and understand why no one should sign it and why it is really something other than what it appears to be.


Here are 12 reasons why no parent can sign this document unless they are interested in being statutorily charged with neglect or intentionally causing harm. Repeating more boldly: this document, if signed, could be used to have your child(ren) removed from your custody! It was created to stand up in court, which is why they require the parent’s signature to be “witnessed”?

Refusal to Vaccinate 3

The document attaches a child ID # that will be identifiable in the electronic records system across the country. Everyone from the school to the NSA will be able to determine who is and who is not vaccinated.

The scientific term for HPV vaccine is listed to discourage parents from making the connection to the dangerous vaccine for HPV called Gardasil. [See Gardasil: Former Merck Doctor predicts greatest medical scandal of all time]

Establishing a vaccination history is part of the Police state registry system being set up to track your vaccination status.

The CDC Vaccine Information Statement is pure unadulterated propaganda. The vaccination information coverup was documented and exposed in an extremely important paper Health Hazards of Disease Prevention (2011). Also see info about the CDC – #9 (below).

Again the parent is misled to think the truth about vaccine risks is on the CDC web site.The doctor has the vaccine package inserts right in his/her office. Why is it not offered and explained to the parent? The physicians themselves may or may not have read them. However, physicians are certainly aware that if the parents read the ‘official risks’ put out by the drug corporations, they would refuse the vaccines. Full disclosure is almost NEVER a part of the process.

“I understand the following: The risks and benefits of the recommended vaccine(s).” This of course would be agreeing to a false statement. You cannot understand the risks without reading and understanding the package inserts, therefore how can you answer in the affirmative? And what about all of the vaccine facts that aren’t even listed in the package inserts that have been ‘covered up’ for many years?

Parents are falsely told that without vaccines their children could suffer dire illnesses but are not told the dire illnesses/injuries the vaccines themselves could cause . . . including death.

This refers to the “herd immunity myth” of 1933, which has been proven unscientific over and over and over again. Simply put: if other children have been vaccinated – and the vaccines work – they won’t contract a disease from your child.

Entities are listed as “strongly recommending” the vaccine schedule. Again however, parents are NOT given full disclosure as to exactly who/what the entities are and what their motivations might be. Listed on the Refusal to Vaccinate document are the following entities and a brief description of their motivation:

  • The ‘physician’ – is rewarded for administering vaccines by higher reimbursements for his fees. His vaccine “rates” are checked to determine whether or not he/she is entitled to more money. Physicians, public health workers, and drug companies have all been given immunity from any possible lawsuits that may arise as a result of vaccine-caused injury or illness. In other words, if a vaccine harms your child or causes autism you cannot sue any of them. They all have a liability exemption.
  • The American Academy of Pediatrics which is a corporation headquartered in the STATE OF ILLINOIS – that receives lots of money from drug corporations for advertising in their journal, etc. This organization relies heavily on what they falsely believe to be a “government” health advocacy agency known as the Center for Disease Control (CDC).
  • The American Academy of Family Physicians which is a corporation headquartered in the STATE OF KANSAS – that also receives lots of money from drug corporations for advertising in their journal, etc. This organization also relies heavily on what they falsely believe to be a “government” health advocacy agency known as the Center for Disease Control (CDC).
  • The Center for Disease Control (CDC) which is a corporation headquartered in the STATE OF GEORGIA. The CDC IS NOT PART OF A LEGITIMATE GOVERNMENT. Repeat: the CDC IS NOT PART OF A LEGITIMATE GOVERNMENT! It is a private for-profit corporation listed on Dun and Bradstreet that is chartered under the umbrella of the private for-profit UNITED STATES corporation with extremely close ties to the pharmaceutical companies and a sordid history of corruption. [See: CDC Exposed]

Bottom line: all of the above “entities” make more money if they vaccinate our children and even more if our children get sick from the vaccines . . . including the pediatricians themselves.

This is the broadest and most nefarious part of this document.
“Nevertheless, I have decided at this time to decline . . . I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others . . . I therefore agree to tell all health care professionals in all settings what vaccines my child has not received because he or she may need to be isolated or may require immediate medical evaluation and tests that might not be necessary if my child had been vaccinated.”

This is not only deceptive and untruthful [see numbers 2-8] it is asking you to confess that you know you are harming your child (and others) and don’t care. It is asking you to agree to inform any/all people who represent themselves as healthcare “professionals” (not defined) of your child’s vaccination record. You are also consenting to allow undefined healthcare professionals to remove your son or daughter from your care and place him or her in isolation for unproven or unknown exposure to a myriad of undefined communicable diseases – with or without testing.

This is an admission that you understand this contractual document – and its significance – ‘in its entirety’. This means that you accept the false information sited as factual, chose NOT to do what you now know to be good for your child and others (are negligent), obligate yourself to embarrass and confuse your child by tracking and reporting on the vaccines you protected your child from, and give permission for your child to be tested or removed from your care and put in isolation for any ‘supposed’ exposure to any ‘undefined’ communicable disease by anyone calling themselves a healthcare worker. [Ohio Revised Code 3701.13]

In short, the form wants you to attest to the following . . . in writing and in the presence of a witness:

  • You understand you are signing a contract with performance requirements
  • You accept false information as factual and don’t care
  • You don’t care if your child or others are harmed by your decision
  • You agree to volunteer to all pretend healthcare workers your child’s vaccine record
  • You agree to allow others to test and/or isolate your child for unproven exposure to a disease

Here is the kicker. As you are asked to sign, initial and date this document in front of a witness, should a custody dispute ever arise (either between parents or with Child Protective Services) this document could be used against the mother or father that signed it.

In defense of physicians, they have been told – via the instructions accompanying the Refusal to Vaccinate document – that parents could sue them should their sons or daughters come down with any of the diseases vaccines are supposed to prevent. Their fear of being sued is why physicians are so insistent that parents sign the Refusal to Vaccinate document.  An excellent alternative, for both physician and parent, is the Vaccination Notice.  This notice corrects misconceptions about vaccines, the herd immunity myth, and the CDC. It also brings the liability (or lack thereof) to the physicians attention. See The Vaccination Notice.


If you have already signed the Refusal to Vaccinate document, go to this page for suggestions as how to rescind or nullify it:  So you’ve signed the Refusal to Vaccinate document


50 responses to “DO NOT SIGN the Refusal to Vaccinate form!

  1. Instead, have your doctor sign the “Physician’s Warranty of Vaccine Safety” found here (scroll down)

    Liked by 1 person

    • Physicians will never sign this. They have never signed anything warranting that their treatments will make you better.


    • 1) if you feel so strongly they are wrong, why don’t you actually go to and ACIP meeting and discuss your concerns? Bet you haven’t done that…

      2) Because many have legitimate concerns for the need for the present schedule of vaccines, there is actually a way to communicate your concerns and even become involved in the process for selecting the vaccine schedule. You can actually see the discussions and names of the individuals engaged in generating the vaccine schedule and discover why the present vaccine schedule exists, the information is freely available. You can go to any meeting, the schedule is posted.


  2. Do you know if this can be used in Canada as well? Also I’d like to have more info before school year starts related to hepatitis b and the “mandatory” meningococcal vaccine, thank you!


    • No vaccines today are warranted by the manufacturers as either safe or effective.

      Are the physicians in Canada using the “Refusal to Vaccinate” document?

      If Canadians wish to use the Vaccination Notice, they need to modify the template to include their institutions.

      Liked by 2 people

  3. Pingback: DO NOT SIGN the Refusal to Vaccinate form! | Elemental Research, Inc.

  4. Here in Idaho they are not allowing me to use the exemption form and are sending it back with their state exemption form. They are not accepting it. Can they force me to use their form?


  5. There is another MAJOR trap here which grants them jurisdiction; there is a clear distinction between common-law which is all living already established God-given natural rights and CIVIL law which is mercantile law and pertains to only contracts between legal fictions;

    Agents employ LEGALESE which sounds like English , but deceptively different. People, as defendants in court, are unknowingly pressed into admitting to be the ALL CAPITALS NAME, a legal fiction ‘debtor’, a ‘citizen’ and ‘subject to rights and duties’. Semantic deceit is employed to get you to admit that your biological offspring are “children” and you are the “mother” or “father” which are CIVIL terms relating to legal fictions. By people un-knowingly admitting to be legal fictions are now ‘subject to rights and duties’ and made your ‘issue’ a ward of the state.

    This device results in a change of status from a living jurisdiction to a contrary legal fiction jurisdiction and like oil and water the two cannot mix. Government is a legal fiction and has no jurisdiction over a sovereign or their private property. We have extensive documents on sovereign rights. Hope this helps. Be blessed.

    Liked by 1 person

  6. We live in a Matrix! Already heard whispers? This post makes it so! Many minds can dissemble the dark Matrix. Get thinking! 144,000 needed and the Matrix will collapse in a heartbeat. It is the will of God!

    Liked by 1 person

  7. please make viral on facebook and twitter….immediately.


  8. Bless your work. Fortunately I do not live in the USA, but I know what is in the USA today will arrive in Europe within a short time. so the battle is taking place there. Those with the knowledge need to get solid information out to all people worldwide on claiming our sovereignty and what action to evade the legal fiction attachments.


  9. Reblogged this on demetrius13 and commented:
    It’s such a shame that it comes down to this…. so Just Say NOOO to toxic vaccines.


  10. I was presented with this paper as a way of opting out of my Grand childrens Vaccinations.. They have had no shots since 2009-when I obtained custody. I have had the Tx State Opt out when I was presented with this..they made it sound like their office had made these up for their protection. My Grand daughter is 18 now.. her brother is 16.. what do I need to do to take this OUT of their record? Also there is a thing called Immtrac.. if you do not go online and take the children off of it… the State has all the shot records. It is very confusing to me!!


  11. Pingback: Death by Doctor | sundayupdate

  12. So I read that it says they will document with a witness that if you refuse to sign the refusal so what do you do?


  13. Newton Shroder

    Hey suggestions , I Appreciate the specifics , Does someone know if I would be able to grab a template a form copy to edit ?


  14. So what happens, if you do not sign the form? You do not get the exemption? I cannot have my child vaccinated again, he almost died from a flu shot and has Kawasaki’s disease from it…what do i do, I live in FL and son is in public school? Doctor will not give waiver…would only give one to another flu shot???


  15. So basically our kids is at harm with the vaccinations and they are at harm with out them. This is really a no win situation and it hurts me to my heart and also they will not let your kids in school with out proper shots.


    • Our children are not in harms way without the vaccines. They are healthier.

      If there is any way you can home school, it would be far better for your children. Once you learn about the problems with Common Core, you will be motivated to make that change.


  16. I have two children, ages 4 and 7 months, my mommy instincts are telling me not to vaccinate them anymore, I read all the comments and I’m just confused. What is the proper way to stop the vaccinations without cps trying to remove them from my custody. I live in st.Louis Missouri. And how do you home school your children.


  17. Mercury ` is in these, VACCINATIONS! ¥


  18. I’m currently overseas working at a naval hospital and I just had an infant. I declined the pregnancy tdap and the newborn shots. They had me sign something that said I was refusing vaccines but it didn’t look like the form you have here. I signed it before doing my research. I’ve been able to postpone the vaccines until now, my son is 3 months old. I need help creating a refusal to vaccinate notice that’s applicable to my situation.

    Liked by 1 person

  19. So I signed a paper before my daughter started school in a different state almost 2 years ago. Is there anything to be done about it now ?


  20. If you REALLY want to prevent your children being unlawfully vaccinated then, DO NOT REGISTER YOUR CHILD.
    Look at it this way. When you register your vehicle, you then hand over OWNERSHIP to the relevant department, is it the DMV in US, here in the UK it’s the DVLA, we get what’s called a ‘V5’ – A REGISTERED KEEPER document. Read that again, ‘REGISTERED KEEPER’, it means you are NO LONGER the OWNER. It’s the same with ANYTHING you register, you hand over all legal rights to ‘OWN’ it. Why do you think ‘they’ can tow away your vehicle and CRUSH IT if you don’t pay the ‘fine’. If you actually own the vehicle do you really think they could take (steal) YOUR vehicle and destroy it.


  21. BOB and Nancy NSA

    So you want your kids to die? Are they that bad?


  22. Pingback: Parents: DO NOT SIGN the Refusal to Vaccinate form! | Thought Crime Radio



  24. I’m in Pa. Will this refusal to vaccinate work for my state? If not please let me know what else I can do. Thanks.


  25. I accidentally signed the form because they told me it was just a release form for the doctors. When I realized it might be this form I asked for a copy. Within six months of receipt I asked (in email and certified mail) for it be sent back and digital files deleted to me explaining reasons I was mislead, coerced into signing, the date on the form on my signature line was altered without my initial, the statements in the RTF form do not represent my beliefs, and I resent signature as explained on this site. Never heard back and when I went in for next wellness check, asked about it. Local office manager said main manager said can not alter the form to suit parents needs and can’t have original back because then they would have to do it for everyone. I sent email to main manager after 60 of the email and letter (WIPAA deadline) and put them on notice. Email was sent back from office manager saying would get back to me. Been weeks and haven’t heard back from OM.


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