MINNESOTA - IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)Minnesota Current Statutes & Laws: http://www.909shot.com/state-site/Minnesota.htm Medical, Religious & Philosophical (notarization required on exemption for schools & colleges) Free or Low-Cost Places to Get Your Conscientious Objection Form Notarized: http://www.health.state.mn.us/divs/idepc/immunize/laws/notary.html To do this, you may either... Use the MDH pupil health record form  (.pdf) English: http://www.health.state.mn.us/divs/idepc/immunize/140-0155.pdf or Spanish: http://www.health.state.mn.us/divs/idepc/immunize/140-0652.pdf, which has a place for a parent's/guardian's signature and the notary's stamp, or... Make your own form stating your conscientious objection to specific immunization(s) and sign it and have it notarized. Like this one... http://distance.minnesota.edu/programs/nursing/Conscientious.php Note: The parent/guardian must sign the form in front of the notary If a notarized statement signed by the minor child's parent or by the emancipated person is submitted to the person having supervision of the school or child care facility stating that the person has not been immunized as prescribed because of the conscientiously held beliefs of the parent of the minor child or of the emancipated person, the immunizations specified in the statement shall not be required. This statement must also be forwarded to the commissioner of the department of health.
Exemption Letters & Forms... Birth Exemptions: For those who are planning a hospital birth but want to evade invasive routine post natal procedures such as a Hep B shot, vitamin K injection, newborn screening, or the application of silver nitrate in the newborn's eyes, a very specific birthing plan must be submitted to the hospital in advance of the birth. Hospital staff must be informed, in advance, of your needs, wants and desires where your baby and birthing experience are concerned. The same applies to midwives. IMPORTANT! Please download this if you're expecting a child or know someone who is! This proves to the hospital that refusal is allowed for newborn screening in Minnesota. Newborn Screening Provider Manual for Minnesota B-4 Appendix Opt-Out Form Parental Refusal of Newborn Blood Screening Page 49-50 of the pdf document. Print front and back. http://www.health.state.mn.us/divs/fh/mcshn/pdfdocs/nbsprovman.pdf or you can download just the REFUSAL forms... Refusal of Minnesota Newborn Screening (2 pages) (WORD) http://www.health.state.mn.us/divs/fh/mcshn/Docs/nbsrefuse.doc  (.doc) (PDF) http://www.health.state.mn.us/divs/fh/mcshn/pdfdocs/nbsrefuse.pdf (.pdf) http://www.health.state.mn.us/divs/fh/mcshn/nbshome.htm Vitamin K Injection... The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert. (.pdf) http://www.fda.gov/medwatch/SAFETY/2003/03Feb_PI/AquaMEPHYTON_PI.pdf"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."The package insert should be printed out and used along with the birth plan letter, the Refusal of Minnesota Newborn Screening form on pages 49-50 of the manual (above...), and your exemption letter or AFFIDAVIT. This shows the hospital or birthing center that you are aware of the risks of Vitamin K injection, and that they should be too. Alternatives to Vitamin K Prophylaxis... Although oral vitamin K is not licensed for use as a drug by the FDA, drops for oral administration are available. Typically, one drop contains 2 mg. of vitamin K. Contact a midwife in your area, or a birthing supply company (such as birthwithlove.com), or Scientific Botanicals (206 527-5521) where your health care provider can order liquid vitamin K directly. Here's another much safer alternative that your chiropractor or naturopath can order for you. http://www.bioticsresearch.com/Products/BioK.htm A good organic whole food diet along with lots of leafy green vegetables is all that is necessary to prevent vitamin K deficiency in newborns. Sample Vaccine Letters From this website... http://www.vaccines.bizland.com/letters.htm Most states now require the Hepatitis B vaccine for newborns. Many parents are also cornered by emergency room personnel during accident visits. Hospitals nationally are under pressure to utilize every opportunity to score a "hit." If your pediatrician understands your views, get him involved with the hospital. As a last resort, protect your right to receive quality care in the following manner. (Usually, you'll never find anybody in the hospital to sign this simple form): "I certify that the (Name of Vaccine)________ vaccine being administered to (Name of Child)_________ is free from all known and yet unknown zoonotic or human viruses or viral fragments and will not cause acute or chronic illness in the recipient due to viral contamination or as a reaction to the components of this vaccine. (Signature of Physician and Date)_________." If you do get a signature, hold on to the form. (Links to model birth plan letter and acceptance of responsibility) Acceptance of Responsibility. http://www.vaclib.org/legal/accept1.htm Model Birth Plan Letter for Hospital Births. You can attach an exemption from immunizations. In some states, there are religious exemptions from newborn screening tests such as PKU, etc... (.doc)
Model Letter for Hospital Births (Model11425.doc) Model Birth Plan Letter for Hospital Births. This one is more detailed. You can attach an exemption from immunizations. In some states, there are religious exemptions from newborn screening tests such as PKU, etc... (.doc) Model letter for hospital births 2.doc (11426) Model Birth Plan Letter for Hospital Births for an adopted child... Model letter for hospital births for adoptions -- Dear Doctor and Medical Staff.doc (11427) (.doc) VaccineTruth.net/letters/Model letter for hospital births for adoptions.doc
The above documents can also be made available in WordPerfect AFFIDAVIT I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of the Minnesota Republic affirm: Be it known to all courts, governments, and other parties that: Being (a person/people) of Strong Christian Morals, it is against (my/our) Deep, Sincerely Held, Religious Convictions to accept the injection of any foreign substance into (my Body/our Bodies) or the Body of (my/our) Child. 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/our) newborn's body. This written statement to exempt (my/our) newborn from any immunizations, newborn screening, and the Vitamin K shot, because (I/we) hold genuine and sincere personal religious beliefs which are inconsistent with these medical procedures & experimentation. The practice of vaccination and the injection or application of any foreign substance is contrary to (my/our) conscientiously held religious beliefs and practices, and violates the free exercise of (my/our) religious principles. The Hepatitis-B vaccine supposedly protects against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps (my/our) parental authority to condemn such activity in (my/our) child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of (my/our) faith. The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert. http://www.fda.gov/medwatch/SAFETY/2003/03Feb_PI/AquaMEPHYTON_PI.pdf "WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."A conflict arises because (my/our) religious convictions are predicated on the belief that all life is sacred. God's commandment "Thou Shall Not Kill" applies to the practice of injection of carcinogenic substances that can kill. (We / I) {First and Last name(s)}, as the {(parent (s) / guardian(s)} of ______________________(name of newborn child) are exercising (our/my) rights under the First Amendment of the US Constitution and [insert Minnesota immunization/testing exemptions birth statutes here] to receive Religious Exemption from Vaccination, ALL injections, & 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/our bodies) and that of (my/our) family that (I/we) can accept. (I/We) affirm that vaccination & injections of any foreign substances and proteins conflict with (my/our) religious beliefs as stated above. Therefore, (I/we) would request that you accommodate (my/our) religious beliefs and practices by exempting (my/our) newborn child from any vaccinations, injections and testing of any kind. Rest assured that (my family and I/our family) do practice a form of immunization that keeps our immune systems 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 Minnesota 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 above AFFIDAVIT is available in Microsoft Word  (.doc) and WordPerfect  (.wpd) format.Click here to Contact Donna. Postnatal - 2 months (first "well baby" visit): If you do take your new baby to an MD as opposed to a naturopath and/or chiropractor, please be aware and careful of any forms you sign. We're referring to those "Refusal To Vaccinate" forms put out by the American Academy of Pediatrics. Go to this page below and find out why signing this form is very dangerous. We all know about these forms and how they can be used to undermine parental rights... http://www.vaclib.org/legal/donotsign.htm Generic Vaccine Refusal Form from Dr. Sherri Tenpenny's webpage. (.pdf) http://www.nmaseminars.com/files/Vaccine_Refusal_Form.pdfState Form Required: No. However, there is a standard immunization form, that includes the exemption, that is used for preschools, schools & colleges. Daycare & Preschools: Exemption form page only. This can be used for colleges too. It must be notarized. (.pdf)
VaccineTruth.net/letters/MN11403.pdf
From this PAGE... (.pdf)
Child Care Immunization RecordI hereby certify by notarization that: ___ I am opposed to all immunizations. ___ I am opposed to only the vaccines indicated and have had my physician or health care provider complete Section B above. Vaccine(s) I oppose are: ______________ ___________________________________________________________________ Registro de vacunación para guardería (.pdf)
Spanish version (PDF: 42 KB/ 2 pages)Certifico ante notario que: ___ Me opongo a todas las vacunaciones. ___ Sólo me opongo a las vacunas indicadas y mi médico o proveedor de atención médica ha completado la Sección B anterior. La vacuna o vacunas a las que me opongo son: ________________________________________________________ ___________________________________________________________________ (.pdf)
ECSE Immunization Record (PDF: 96KB/1 page)Children in the Early Childhood Special Education (ECSE) program must have this completed form on file with the school. I hereby certify by notarization that: ___ I am opposed to all immunizations. ___ I am opposed to only the vaccines indicated and have had my physician or health care provider complete Section B above. Vaccine(s) I oppose are: ______________ ___________________________________________________________________ INDEPENDENT SCHOOL DISTRICT 196 Rosemount, Minnesota 55068-4199 SERIES NUMBER 501.3P ADOPTED April 1994 REVISED June 1995 TITLE Conscientious Objection to Early Childhood Screening (.pdf) http://www.isd196.k12.mn.us/pdf_files/onlinepolicies/500/501.3P.pdf Duluth Public Schools (.pdf)
http://www.duluth.k12.mn.us/nurses/Forms/exemp.pdf MN child care and school statute 121A.15 Health standards; immunizations; school children. Schools: This form is for use in all public schools. Exemption form page only. This can be used for colleges too. It must be notarized. (.pdf) VaccineTruth.net/letters/MN11403.pdfForms Farmington Public Schools - Independent School District 192 Immunization Record Form ( PDF Version or Microsoft Word) This form is for use in all public schools in Minneapolis. Immunization Exemption is on page 2 (.pdf)
http://health.mpls.k12.mn.us/sites/287ade6f-54c9-490d-b270-f0e7565f842e/uploads/Form_107_for_2004_2.pdf (.doc) ISD #534 STEWARTVILLE PUBLIC SCHOOLS District Exempt.doc (.pdf) ISD #534 STEWARTVILLE PUBLIC SCHOOLS District Exempt.pdf (.wpd) ISD #534 STEWARTVILLE PUBLIC SCHOOLS District Exempt.wpdThis exemption form has been made available in Word Pefect and Adobe PDF format. Duluth Public Schools (.pdf)
http://www.duluth.k12.mn.us/nurses/Forms/exemp.pdf MN child care and school statute 121A.15 Health standards; immunizations; school children. Camps/Other: MN Teen Challenge pg 23 (.pdf)
http://www.mntc.org/pdf/LC_Adolescent.pdfOpt-Outs: Military Recruiters: STUDENT OPT OUT FORM regarding the RELEASE OF NAME, ADDRESS, AND TELEPHONE NUMBER TO MILITARY RECRUITERS (.pdf) http://www.militaryfreeschools.org/PDF/optout2.pdfUNDERGROUND ACTION ALLIANCE STUDENT OPT OUT FORM (.pdf) http://www.militaryfreezone.org/opt_out.pdf (.doc) http://veterans4peace.org/opt_out.docSAMPLE ENGLISH - BINGUAL FORMS FOR OPTING OUT Act to Protect Your Privacy from Military Recruiters (.pdf) http://www.afsc.org/pacificsw/documents/Opt-Out-Form.pdf STUDENT OPT-OUT - Google Search STUDENT OPT-OUT NOTICE regarding the instruction of sexuality to children: STUDENT OPT-OUT NOTICE Valid in all 50 states (.pdf) http://www.ccv.org/images/StudentOptOutNotice.PDF (.pdf) http://www.catholiccitizens.org/content/img/f26422/opt%20out%20notice.pdf (.html) http://www.ccv.org/images/StudentOptOutNotice.htm
Entire packet... (.doc) http://www.mfc.org/respect/Website/Links%20on%20Web%20Page/Opt-Out%20Packet.docSTUDENT OPT-OUT NOTICE - Google Search Colleges and Universities: Exemption form page only. This can be used for colleges too. It must be notarized. (.pdf) VaccineTruth.net/letters/MN11403.pdf
Southwest Minnesota State University (.pdf)
http://www.southwest.msus.edu/edl/pdf/GradImmunizaonRecord5.0.pdf Concordia University IMMUNIZATION RECORD FOR POST-SECONDARY SCHOOLS (.doc)
http://web.csp.edu/health_wellness/media/immunization_record_for_post.docGeneric This form is designed to provide Concordia University with the information required by Minnesota Law(M.S.135A.14) and will be available for review by the Minnesota Department of Health and the local community health board upon request. If your school is not listed on this page, you may use above form and replace Concordia with the name of your college or university. Ridgewater College (.pdf)
http://www.ridgewater.edu/Common/assets/pdf/Immunization%20Form.pdfWinona State University P.O. Box 5838 Winona, MN 55987 (.pdf)
http://www.winona.edu/graduatestudy/forms/ImmForm.pdfUniversith of Minnesota - Crookston Student Health Services, 145F Student Center, U of MN, Crookston, MN 56716 Conscientious Exemption on page 2 of Health History Form. (.pdf)
http://www.umcrookston.edu/services/healthservices/Forms/MedHistory-Fm.pdfUniversity of Minnesota (.pdf) http://www.unite.umn.edu/MainSite/Forms/Immunization%20Form.pdf University of St. Thomas (.pdf) http://www.stthomas.edu/oiss/orientation/files/Immunization.pdf Crossroads College - Rochester, MN (.pdf) http://www.crossroadscollege.edu/images/PDF/Admissons/Health%20form.PDF Anoka - Ramsey Community College (.pdf) http://www.an.cc.mn.us/resources/pdf/immunization/immunization.pdf Bethel College (.pdf) http://cas.bethel.edu/student-development/health-services/cgcs-immunization.pdf
College of St. Scholastica
TB Testing Exemption Letter: TB Testing Alternatives... TB can be detected by biofeedback machines that are hooked up to a computer, such as the QXCI, Best BioMeridian MSAS (Meridian Stress Assessment) or Electro Dermal Screening, Quantum Life System, and the F-Scan. You will need to ask specifically for a pathogen scan, especially TB. You will also need to request a printout with the results. Here are some of the practitioners for Minnesota Minnesota BEST™ BioMeridian Practitioners: Benessere Body in Balance Kay Troan 125 Main St. SE, Suite 237 Minneapolis, Minnesota 612-378-WELL (9355) / 1-888-499-WELL (9355) http://www.benesserebodyinbalance.com/ MSAS, Meridian Stress Assessment System. The MSAS is the latest technology available in meridian stress assessment. The MSAS' primary objectives are to disclose patterns of stress and to provide feedback for use in a program that helps restore each system and meridian to a natural balance. It is a completely non-invasive method for gaining valuable information about the body's vital functions. Please call contact below to find additional BioMeridian practitioners in your area or closeby. Oksana Gorodetsky Marketing/Administrative Coordinator BioMeridian International 12411 South 265 West, Suite F Draper, UT 84020 T 801-501-7517 F 801-501-7518 Toll Free 888-224-2337 ogorodetsky@biomeridian.com Minnesota QXCI Practitioners: http://www.theqxci.com/practitioners.php#central Main page of practitioners: http://www.theqxci.com/information.php Kathy Beehler Quantum Consultant General EPFX / QXCI Practitioner Bemidji, MN 56601 218-243-2958 For information on purchase or lease of the new Quantum Life BioFeedback L.I.F.E. System, please email Donna and leave your name, mailing address, phone number and email. If you're inquiring for another interested individual or practitioner, please leave their information. The company will then send information and contact the interested parties. Or you may call 1-888-249-1421. Immunization Registry Opt Out: Minnesota ImmuLink Immunization Registry Opt Out Form http://www.co.hennepin.mn.us/vgn/images/portal/cit_100003616/16/52/100450364OPT%20OUT%20FORM%202000.doc The Opt Out Form can be made available in PDF format. Email us if you want it converted to PDF. Information on this page is provided and sponsored by: |
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