(includes current statutes, letters & forms)

IMMUNIZATION EXEMPTIONS by State (includes current statutes, letters & forms)

Note: Be advised that websites and links change constantly. It would be wise to go through this page and save ALL the exemption forms and letters, in case a website goes down. Please share with others who also want to refrain from medical experimentation.


Current Statutes & Laws:
Medical & Religious

Submitted to the admitting official: An affidavit signed by the student or, if he or she is a minor, by a legally authorized representative of the student, stating that the immunization conflicts w ith the tenets and practice of a recognized religious denomination of which the student is an adherent or member or that immunization conflicts with the personal and sincerely followed religious beliefs of the student.

For additional help with exemptions, birth plan,etc questions:

Check our Vaccination Liberation State Chapter and other resource organizations page for help in your state.

If your state specific help is not available, Contact us.

PDF documents (.pdf)

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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.
Note:   Newborn testing is mandatory in Nebraska. No exemptions are allowed at this time. It's possible that newborn testing via biofeedback may be accepted. See the bottom of this page for the list of Biomerdian and QXCI practitioners in your area.

Vitamin K Injection...

The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert.
"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."
Merck Vitamin K Package Insert - Aquamephyton PI | Scribd

The package insert should be printed out and used along with the birth plan letter, 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, or Scientific Botanicals (206 527-5521) where your health care provider can order liquid vitamin K directly.

Here's another safe alternative that your chiropractor or naturopath can order for you. Or order directly from

Biotics Research, Bio-K Mulsion - 1 fl oz

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...
from archived on

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.

Hepatitis B Vaccine Refusal formerly found on Dr. Sherri Tenpenny's webpage:
File Info : Sherri Tenpenny
Contents :
To All Doctors and hospital personnel:
This is to inform you that we are refusing the hepatitis B shot for our new born baby. This letter is intended to supersede any consent implied or otherwise to papers signed at the time of or before hospital admission for the birth of our child. The legal position on this is clear: however convinced a doctor or nurse may be that certain a treatment is in a patient's best interest no medical treatment may be given without the patient's consent. We want to be very clearly understood: we do NOT give consent for the vaccine to be given. Sincerely
mother father

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...

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 (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) letter for hospital births for adoptions.doc

The above documents can also be made available in WordPerfect (.wpd) format.
Please contact us if you want the model birth plan letters in WordPerfect.

The birth plan arrangements and letter should be turned in before delievery date.
This "Refusal to Permit Medical Treatment" form is optional to use.

"Refusal to Permit Medical Treatment" form
Refusal to Permit Medical Treatment. A generic form.
(.pdf) Originally found at: ../letters/refusal_treatment.pdf

You may write a religious exemption letter or statement refusing the Vitamin K injection and Hepatitis B vaccine. At this time, there is no exemption for refusal of newborn testing. However, you could try the biofeedback practitioners at the bottom of the page to test for newborn disorders. There is no guarantee, that they would accept it in lieu of the heel pricking, but it's worth a try. The law in Nebraska must be repealed, for parents to have a choice in what they feel is best for their newborn, not the state.
The ACCEPTANCE OF RESPONSIBILITY is imperative in exercising your rights for legal exemptions from forced medical experimentation and legalized bioterrorism. DO be prepared to fight for your baby's rights!

State Form Required: No

Daycare & Preschools:

Use the school forms below.


Each school in Nebraska is required to keep on file the immunization history of the students enrolled. Parents or guardians must present one of three documents to the school to verify immunization status:

Nebraska State Immunization Information System (NESIIS) Forms

Refusal of Immunization for Medical Reasons (pdf)
Refusal of Immunization of Student for Religious Reasons (pdf)

Lincoln Public Schools

Did not find your state exemption form on our site?
Then try this link to forms for all 50 states and D. of Columbia.

Colleges & Universities:

Nebraska State Immunization Information System (NESIIS) Forms

Refusal of Immunization for Medical Reasons (pdf)
Refusal of Immunization of Student for Religious Reasons (pdf)

Chadron State College Immunization Waiver Form

University of Nebraska Medical Center
Vaccinia Vaccine Waiver
Current Link:
(.pdf) (.doc) IBC Forms
Vaccinia Vaccine Waiver

Web Archive Link:
(.doc) Index of Forms:
Vaccinia Vaccine Waiver
Vaccinia Vaccine Waiver

Concordia University Nebraska
On medical history form
Request for Waiver of Immunizations, bottom of page. 2
Religious exemption: I request exemption based on religious beliefs, understanding that in the event of an outbreak I will be barred from campus for the duration of the outbreak which could last several weeks.
Signature __________________________________________ Date _____________

Meningitis Information Acknowledgment
__ We do not want our child to receive the vaccine at this time.

These Google searches 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


Most of these are the Hepatitis B vaccine declination forms, such as the OSHA form. There are hundreds of these forms. Rather than linking to each one, here are the Google Search results for these keywords. There are other vaccines that one can decline that are worded like the OSHA forms.

Vaccine Declination Form
Hep B vaccine waiver

TB and/or Lead Testing


Generic letter for Exemption to TB Testing:
HTML (text): Exemption-tb-test.html

MS Doc file: Exemption-tb-test.doc

Standard Interpretations
09/23/1997 - The Bloodborne Pathogen Standard and the Enforcement Procedures for TB.
"Finally, be aware that participation in the employer's skin testing program is voluntary on the part of the employee. OSHA does not require that employees participate in TB skin testing, only that the employer make such skin testing available to employees."
TB and Lead Testing Links:
F L Y E R    LETTER    Exemption_Letters    OSHA_and_TB_test    Tubersol    Treatment    TB_Screening    Alternatives/QuantiFERON_TB_Gold_testimony

The above TB and Lead exemption letters are courtesy of Deirdre DeVane of Wash DC. Thank you Deirdre!
The adult TB letters were edited by Sherri Tenpenny. Thank you Sherri!

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 Nebraska

Nebraska BEST™ BioMeridian Practitioners:

Skyline Chiropractic
Sarah Emanuel, D.C.
1061 Road 16
Rogers, NE 68659
(402) 352-5055
Techniques Used: TBM, Sacral Occipital Technique (SOT), Meridian Stress Assessment

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

Nebraska QXCI Practitioners:

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 1-407-672-6144.

Information on this page is provided and sponsored by:

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Vaccination Liberation - Idaho Chapter
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"Free Your Mind....From The Vaccine Paradigm"

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