Georgia State Exemption Information

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Kindergarten & Schools
Exemption VacLib-GA.doc

(.doc) VaccineTruth.net/letters/ExemptionVacLib-Georgia.doc

(.wpd) VaccineTruth.net/letters/ExemptionVacLib-Georgia.wpd

Cobb County School District
Form JLC-4
WAIVER OF IMMUNIZATION REQUIREMENTS
DUE TO CONFLICT OF RELIGIOUS BELIEFS

(.doc) http://www.cobb.k12.ga.us/centraloffice/adminrules/J_Rules/Form%20JLC-4.doc

A letter that was used to exempt a child from Hep B vaccine...

Mrs. Jane Doe
123 Any Road
Your City, Georgia. 00000

School _________________________________________

Statement of Religious Objection to Immunization

In accordance with Georgia Immunization program O.C.G.A. § 20-2-771

I hereby certify that the administration of any vaccine and other immunizing agents to my child, ____________, is contrary to our personal Religious beliefs, held either individually or jointly with others, and I therefore request that my child be exempted from the school immunization requirements as set forth O.C.G.A. § 20-2-771(e)

We believe in God, and that God has created us in his image. We are bestowed with His gift, the immune system. I believe it is sacrilegious and a violation of our sacred religious beliefs to violate what God has given us by injected our bodies with vaccines known to cause immune system damage.

We believe that God does not want us to harm our bodies. After much research we believe vaccine to be harmful to the body. They contain toxic ingredients (i.e. Thimerosal, Formaldehyde, Ethylene glycol, Phenol, etc.) that can weaken the immune system and cause illness, lasting damage or death. Many vaccines contain human aborted fetal tissue cells (i.e. Rubella, Chickenpox, Hep A, and some brands of injected polio). This is highly against our beliefs to use any part or benefit from anything doing with the abortion of a human life.

The Hepatitis-B vaccine was designed to protect against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps my parental authority to condemn such activity in my children. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of our faith. With all this, we believe that vaccination is against our personal religious beliefs and wrong in the eyes of God.

Parent __________________________________ Date _______________

Parent __________________________________ Date _______________

Subscribed and Sworn before me this _____ day of ___________, 20____.

________________________________________
Notary's Signature and Seal

O.C.G.A. § 20-2-771(e)

(e) This Code section shall not apply to a child whose parent or legal guardian objects to immunization of the child on the grounds that the immunization conflicts with the religious beliefs of the parent or guardian; however, the immunization may be required in cases when such disease is in epidemic stages. For a child to be exempt from immunization on religious grounds, the parent or guardian must first furnish the responsible official of the school or facility an affidavit in which the parent or guardian swears or affirms that the immunization required conflicts with the religious beliefs of the parent or guardian.

Sample Religious Affidavit found online...

Here is an example of a religious exemption I made up a few months ago. This one uses the Georgia Code as an example.

----------------------------------
An Example Affidavit

-First copy & paste the code from your state. Example follows:

[Education, Part III, Health, Ga. Code Ann. §20-2-771. Rules of Department of Human Resources Public Health, Ga. Comp. R. & Regs.§ 290-5-4-. 01 to .09.]

-Then copy & paste the section that pertains to religious exemption. Example:

[A child may be exempted on religious grounds if a parent furnishes an affidavit swearing that the immunization required conflicts with the religious beliefs of the parent. The immunization may be required in cases when such disease is in epidemic stages. O.C.G.A. § 20-2-771(e). Religious belief in divine healing through faith not to excuse refusal to have children vaccinated. son v. State, 84 Ga. App. 259, 65 S.E. 2d 848 (1951).]

-Then continue with the following:

Pursuant to the aforementioned (insert above code), I, the undersigned, declare the immunization requirements as set forth in O.C.G.A. § 20-2-771(e) contrary to my bona fide religious beliefs and request, as permitted by the law, an exemption from the immunization requirements of your institution for myself or the undersigned minor child under my legal care or guardianship.

NAME ______________________________________

SIGNATURE__________________________________

ADDRESS____________________________________

___________________________________________

PHONE_____________________________________

DATE_______________________________________

___ Check here if declaring exemption for a minor child and enter child's name below.

MINOR CHILD'S NAME _________________________________________

ADDRESS______________________________________

_______________________________________________

PHONE_________________________________________

DATE___________________________________________

----------------------------

**A nice, professional looking affidavit. BTW, they are not allowed to ask your religion.
__________________

**This can be copied to Wordpad & edited to your needs.

Note: Exemption letters, affidavits, and statements must all be notarized in Georgia.
__________________

Cobb County School District
JF-5: Objection to the Use of Social Security Number
English and Korean:
http://www.cobb.k12.ga.us/centraloffice/adminrules/j_rules/Form_JF-5_Kor.pdf

Colleges/Universities

(.doc) VaccineTruth.net/letters/ImmunizationGeorgia11412.doc

ϑ RELIGIOUS EXEMPTION
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
__________________________________________________________________
Signature of student (required ONLY for religious exemption) Date

Floyd College
3175 Cedartown Hwy., SE, P.O. Box 1864 - Rome, Georgia 30162-1864
CERTIFICATE OF IMMUNIZATION
Bottom of form, page 2.
Part III – Exemptions
I,____________________________________affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.

(.pdf) https://www.applyweb.com/apply/floyd/immune.pdf

Berry College - 2277 Martha Berry Hwy NW • Mount Berry, GA 30149
Meningitis Vaccination Record/Waiver

(.pdf) http://www.berry.edu/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=7828&libID=7844
Check off the Religious Exemption at the bottom of the page of the form. Signature is required.

(.pdf) http://www.berry.edu/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=7827&libID=7843

EXEMPTIONS:
______ Exemption on grounds of permanent medical contraindication
______ Exemption on grounds of temporary medical contraindication
______ A. Pregnancy, expected delivery date: _____/_____
______ B. Other, anticipated date of contraindication's end: _____/_____
______ Religious exemption: I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs.

I understand that exemption for any of the reasons listed above subjects me to exclusion from campus in the event of an outbreak of a disease for which immunization is required.

Signature of Student:___________________________________________Date: ____/____/______

GEORGIA PERIMETER COLLEGE
Religious Exemption at the bottom of Page 2

(.pdf) http://www.gpc.edu/~je/pdf_files/Immunization%20Form.pdf

Gainsville College (check religious exemption at bottom of form) looks like this...
ϑ RELIGIOUS EXEMPTION
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.

Signature of Student (Student signature required only for religious exemption) Date

(.pdf) https://www.applyweb.com/apply/ugsgc/immunization.pdf

GEORGIA STATE UNIVERSITY
Georgia State University CERTIFICATE OF IMMUNIZATION (effective Spring Semester 2005)
http://www.gsu.edu/images/health_clinic/2010_Immu_Form.pdf

Geogia State University
Form Six CERTIFICATE OF IMMUNIZATION 2005 / 2006 Form
PART III – EXEMPTIONS (bottom of Page 2)
Use AFFIDAVIT below, if asked for additional statement.

(.pdf) http://www.applyweb.com/apply/gsurcb/pdf/immunization.pdf

CERTIFICATE OF IMMUNIZATION
University System of Georgia
Religious Exemption bottom of page. Only a signature is required.

(.pdf) http://www.applyweb.com/apply/asu/immunization.pdf

GEORGIA COLLEGE & STATE UNIVERSITY
CERTIFICATE OF IMMUNIZATION
University System of Georgia

(.pdf) www.gcsu.edu/docs/Immunization_Certificate.pdf

University of West Georgia
Carrollton, Ga. 30118-4700

(.pdf) http://www.westga.edu/~gradsch/forms/printable/Immunization.pdf
Only a signature is required.

Kennesaw State University
Religious Exemption : I affirm that immunizations are in conflict with my religious beliefs. I understand that I may be subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
Sign at the bottom of page.
Signature (only if declaring religious exemption) ________________________ Date ______________

(.pdf) http://www.kennesaw.edu/col_hhs/hc/immunization.pdf

BAINBRIDGE COLLEGE
Sign at the bottom of page.
Religious Exemption Request. I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
Signature of Student __________________________________________________Date:_____________________
required if claiming religious exemption

(.pdf) Bainbridge_College/immunization_form.pdf

Gordon College - Barnesville, GA
*********************************************************************************************
     ϑ Religious Exemption
I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required.
     ____________________________________________________________________________
                         Signature of student                                         Date
     (Student signature required only for religious exemption)

(.pdf) http://www.gdn.edu/forms/admissions/Immun_form.PDF

Board of Regents of the University System of Georgia
270 Washington Street, S.W., Atlanta, Georgia 30334
Exemption at bottom of page.

(.pdf) www.usg.edu/student_affairs/documents/coi-form.pdf

Georgia Southern University
Statesboro, GA 30460-8043
Part III – Religious Exemption - Put checkmark and PRINT name of student, only if claiming religious exemption.
Bottom of Page 2

(.pdf) http://services.georgiasouthern.edu/aux/pdf/health/CertificateofImmunizationForm.pdf

GAINESVILLE STATE COLLEGE
Religious Exemption at bottom of first page.

(.pdf) http://www.gsc.edu/admissions/Admissions Documents/Immunization Form.pdf

Armstrong Atlantic State University
11935 Abercorn Street, Savannah, Georgia 31419
Part III – Exemptions
Bottom of Page 2

(.pdf) www.armstrong.edu/images/admissions/immunizationform.pdf

Mercer University
RELIGIOUS EXEMPTION at bottom of form (Must be signed and notarized)

Word Perfect Document (.wpd): http://www.mercer.edu/chc/atlform.wpd

Word Perfect Document (.wpd): Archived Copy of WPD document

Some colleges may ask for an additional statement to be attached. For those other colleges and universities, you may use the AFFIDAVIT for Georgia Adult (college & employment religious exemption) below.

This AFFIDAVIT below is sufficient for a religious exemption statement from MMR and any other vaccines to post secondary institutions. Most colleges now have their mandatory waiver for meningitis. The required documentation informs the postsecondary school, and thus the state, that the student has either been vaccinated for meningococcal meningitis or has chosen to decline the vaccine.
This AFFIDAVIT letter will fit nicely on front and back paper.
AFFIDAVIT for Georgia Adult (college & employment religious exemption) ... Edit as needed...

AFFIDAVIT

I, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being, state Citizen of the Georgia Republic affirm: Be it known to all courts, governments, and other parties that:

Being a person of Strong Christian Morals, it is against my Deep, Sincerely Held, Religious Convictions to accept the injection of any foreign substance into my Body. This includes, but is not limited to, any and all, Vaccinations, Shots, Tests for Diseases, Oral Vaccines, Epidermal Patches and in any other way that Live or Killed Bacterium, Viruses, Pathogens, Germs, or any other Microorganisms, may be introduced into or upon my body.

This written statement to exempt myself from the immunization requirement, and the Mantoux (PPD) Tuberculin Test, because I hold genuine and sincere personal religious beliefs which are inconsistent with these medical procedures and experimentation. The practice of vaccination and the injection of any foreign substance is contrary to my conscientiously held religious beliefs and practices, and violates the free exercise of my religious principles.

The attenuated virus used to produce the Rubella vaccine (RA27/3) was obtained from an aborted fetus and then cultivated on fetal tissue from another aborted baby (WI-38), and is also in the rubella portion of the MMR-II vaccine. The Chickenpox vaccine containing WI-38, MRC-5 and Hepatitis-A vaccine (MRC-5) were obtained from human babies that were electively aborted. A conflict arises because my religious convictions are predicated on the belief that all life is sacred. God's commandment "Thou Shall Not Kill" applies to the practice of abortion. The acceptance of these vaccines promotes abortion and violates the Sixth Commandment of "Thou Shall Not Kill". The Hepatitis-B vaccine protects against a disease that is only transmitted through multiple sexual partners or street IV drug users. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of my faith.

I, {First and Last name}, am exercising my rights under the First Amendment of the US Constitution, Georgia code, 1-4-13(a) and Georgia code 49-4-183(10)(C) to receive Religious Exemption from Vaccination & testing.

Applicable law has been interpreted to mean that a religious belief is subject to protection even though no religious group espouses such beliefs or the fact that the religious group to which the individual professes to belong may not advocate or require such belief. Title VII of the Civil Rights Act of 1964 as amended Nov. 1, 1980; Part 1605.1-Guidelines on Discrimination Because of Religion.

Our legal rights are guaranteed by the free exercise clause of the First Amendment to the U.S. Constitution. Recent court decisions have upheld the rights of individuals seeking exemptions from immunizations based upon personal and religious reasons. On the U.S. Supreme Court level in Frazee V. Illinois Dept. of Security, 489 U.S. 829, it was found that a state may not deny an exemption simply because a person is not a member of a formal religious organization.

The Lord Jesus Christ and Our Creator are the only source of protection of my body and that of my family that I can accept.

I affirm that vaccination & injections of foreign proteins conflict with my religious belief as stated above. Therefore, I would request that you accommodate my religious beliefs and practices by exempting me from the college vaccination and TB testing requirement.

Rest assured that I do practice a form of immunization that keeps my immune system strong and is in keeping with Biblical principles.

Further Affiant Saith Not

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, (Print Name Below)

_______________________________________________________________,
Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.

_______________________________
Signature of Affiant

      ACKNOWLEDGMENT

state of Georgia

county of _________________:

On this _______ day of ______________, 200__, 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 ______________________________, 200___

The Google searches belwo are mostly the college and school exemptions. There are always new forms coming online. Keep a regular check on these to look for newly added forms. Some are for daycare too. The links are the actual keywords that are used.

Immunization Exemption Form

Vaccine Exemption Form

Immunization Waiver

Employment:

(.doc) VaccineTruth.net/letters/Immunization GA employment.doc

These forms read like the OSHA Hep B forms, but are covering the MMR/Smallpox Vaccines

Emory University
Vaccine Consent/Declination Form for all but Hep B

(.pdf) http://www.ehso.emory.edu/content-forms/ImmunizationReviewandDeclinationForm_nonHepB.pdf

Emory University
Hep B Vaccine Consent/Declination Form

(.pdf) http://www.ehso.emory.edu/content-forms/ImmunizationReviewandDeclinationForm_HepB.pdf

Return To: Immunization Coordinator
Environmental Health and Safety Office
Emory University, School of Medicine
1462 Clifton Road, Suite 300
Atlanta, GA 30322

Click for the desired information for your state

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Newborn Screening for Metabolic and Sickle Cell Disorders Program

Screening: Parents Refusal

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