Why You Should Never Sign the Refusal to Vaccinate Form  GF4nkAnhlAWOmsuzPM3NhTl72eJkfbmt4t8yenImKBVvK0kTmF0xjctABnaLJIm9

It has become increasingly clear that a large part of the Covid-19 debacle has been to coerce and otherwise force a deadly DNA altering toxic shot upon the whole of the population under the disguise of a mass vaccination campaign to combat a “pandemic”. Those of us who have been diligently following the science (not CNN, Fauci and the CDC) know that not only is there no pandemic, this shot is not a true vaccine. By legal definition it is a device. It cannot prevent transmission of Covid-19 and it does not act to create immunity. The only thing it has been proven to do so far is kill tens of thousands of people and cause serious adverse reactions in millions of people with many suffering from permanent injury, including neurological disorders, blindness, paralysis and seizures.

The long term effects of this experimental gene therapy are yet to be seen but many experts, including the former head of Pfizer himself have stated that this so-called vaccine will lead to infertility, auto-immune disorders and premature death for all those who receive it. The unthinkable truth is this: there is a serious plot to depopulate the earth and it is pushing forward at warp speed.

As the agenda now moves it’s focus to injecting our children, we must do everything we can to protect the next generation! Please share the following document with every parent you know. This document can be used to ensure that all those who interact with your child while they are outside of your home understand that under no circumstances are they to ever believe that your child’s presence is to be considered ‘implied consent’ for them to be vaccinated.

A WHO spokesperson has explained that in an implied consent process, “parents are informed of imminent vaccination through social mobilisation and communication, sometimes including letters directly addressed to parents. Subsequently, the physical presence of the child or adolescent, with or without an accompanying parent at the vaccination session, is considered to imply consent.”

If you happen to miss a letter sent home with your child or an email sent by the school and you fail to ‘opt-out’ on vaccination day, your child’s presence in school can be considered consent to be vaccinated.

Use this form to ensure this never happens to your child!

See below for a very important explanation as to why you should NEVER SIGN A ‘REFUSAL TO VACCINATE’ form!


As the mother/father of [Sally Doe], born on [6-5-10] and who lives with me at  [2525 Aloha Lane, Honolulu, Hi, zip],  I am prohibited by law from endangering my [son or daughter]; therefore I declare the following:

1) I am aware that those ordering and/or administering vaccines have been granted immunity from liability should my [son or daughter] suffer from a vaccine caused injury or illness. Since the Supreme Court decision Bruesewitz v. Wyeth (Feb 22, 2011), drug companies are under no legal obligation to insure their vaccine products are either safe or effective. The same decision defined vaccines as unavoidably unsafe. Vaccine manufacturers pay nothing into the National Vaccine Injury Compensation Program, so it is not an acceptable alternative to me. (Reason listed below – #11)

2) The available Covid-19 vaccines have NOT been approved by the Food and Drug Administration (FDA) and have only been granted emergency use authorization. Due to the fact that several safe and effective therapeutic treatments exist in order to treat Covid-19, and because children have a 0% chance statistically of dying from Covid-19, approval of this experimental medical treatment for emergency use is unlawful and reckless for this age group. See U.S. Code Title 21, Section 564.

3) The Public Readiness and Emergency Preparedness Act (PREP Act) amended the Public Health Service Act (PHS Act) to add section 319F-3 (42 U.S.C. 247d-6d).  The HHS Secretary has issued several Declarations pursuant to section 319F-3 of the PHS Act to provide liability immunity for activities related to medical countermeasures against Covid-19, including vaccination. This means if my child is injured by one of these experimental shots the burden lay entirely upon me and my family with no compensation. 

4) Unless I receive the vaccine manufacturer’s package inserts, I have not been given full disclosure regarding any vaccine. Because alternative sources of scientific information regarding the safety and efficacy of vaccines are highly censored by the Big Tech and corporate media vaccine shareholders, one cannot make an informed decision. Centers for Disease Control (CDC) or public health Vaccine Information Sheets and/or websites are not acceptable alternatives. (Reasons listed below – #6 & #7)

5) I am aware that vaccine schedules have been established by the CDC and are promoted by public health departments, the AMERICAN ACADEMY OF PEDIATRICS and other organizations. I do not accept CDC recommendations as science- based. (Reasons listed below – #6 & #8)

6) I do not recognize the CDC as a government health advocacy organization. It is a corporation listed on Dun and Bradstreet and headquartered in the STATE OF GEORGIA, with strong ties to the pharmaceutical industry through the CDC Foundation. Therefore, their recommendations are influenced by the fiscal health of their corporation.

7) I am aware that the STATE OF HAWAI’I DEPARTMENT OF HEALTH, a corporation headquartered in the STATE OF HAWAI’I and listed on Dun and Bradstreet, receives monetary compensation from the CDC to promote vaccines. Therefore, the state public health department’s recommendations and actions are influenced by the fiscal health of their corporation.

8) I do not recognize the AMERICAN ACADEMY OF PEDIATRICS or the AMERICAN ACADEMY OF FAMILY PHYSICIANS as health advocacy organizations. They are both trade organizations and corporations (listed on Dun and Bradstreet) that are headquartered in the STATE OF ILLINOIS and the STATE OF KANSAS respectively, whose monetary compensation from vaccine manufacturers contributes to the fiscal health of their corporations.

9) I am aware that physicians and hospitals are paid higher reimbursement rates for administering vaccines.

10) I am aware of multiple scientific peer-reviewed papers that have exposed the dangers of many vaccines as well as the herd immunity through vaccination myth.

11) I am aware that the corporation HEALTH & HUMAN SERVICES, UNITED STATES DEPARTMENT OF, listed on Dun and Bradstreet and headquartered in WASHINGTON DC, profits from vaccines patents and determines claims paid from the National Vaccine Injury Compensation Program via a secret administrative process.

11) I have concluded that following the CDC vaccination recommendations can endanger the health or life of my [son or daughter].

For the reasons I have listed, I do not consent to anyone administering any vaccine, especially not a Covid-19 vaccine to my [son or daughter] unless they provide me with the vaccine package insert for each vaccine they wish to administer, allow me to determine if the health risks are acceptable, and sign a document stating that they, in their professional and/or personal capacity, not me (nor my [husband or wife])accept the responsibility and costs for any injury or illness, as defined by the International Medical Council on Vaccination, the vaccine they administer might cause my [son or daughter].

Under no circumstances is my [son or daughter] to receive any injection or medical treatment of any nature without my full verbal and written consent. If my child is present in school on a day where a vaccine clinic is being offered, under NO CIRCUMSTANCES should my child’s presence serve as IMPLIED CONSENT to be vaccinated. Any state laws which act to circumvent the authority of a parent to raise their child as they see fit, by allowing for direct consent of minors, is a constitutional substantive due process violation and damages may be sought under U.S. Code Title 42, Section 1983. 

The Covid-19 vaccine is an experimental, investigational product and all those receiving the injection are considered participants in investigational research until the year 2023. According to the Common Rule (the regulatory statute for research involving human participants in medical research in the United States), research that involves greater than minimal risk but presents the prospect of direct benefit to the children involved, is only considered to be ethical if: 1) “The risk is justified by the anticipated benefit to the subjects”; 2) “The relation of the anticipated benefit to the risk is at least as favorable to the subject as that presented by available alternative approaches”; and 3) “Adequate provisions are made for soliciting the assent of the children and permission of their parents or guardians.” The Common Rule standards highlight the necessity of receiving adequate informed consent when children are involved, and merely distributing information to parents, without the assurance that they have actually read and understand it, does not provide adequate protections for the well-being and lives of the children. Implied consent is entirely unethical in relation to a Covid-19 vaccine when there is absolutely zero benefit and great risk.

NOTE: This document can be used to protect those that administer vaccines (physicians, nurses or others who are obliged to adhere to corporate statutes) from any punitive statutory actions or penalties by acting in lieu of a ‘Refusal to Vaccinate’ form.

Upon signing, this document shall remain legally binding for as long as my/our child is a patient/student/member of your institution and no changes may be made to this contract without full consent by all parties.

Mother’s name: _____________________________________________

Mother’s signature: __________________________________________ Date: _____________

Father’s name: ______________________________________________                                                                        

Father’s signature:____________________________________________________Date:_____________                                                                 

School administrator/physician or other responsible party name:


Signature: _________________________________________________ Date: ____________                                   

Witness name: _____________________________________________

Witness signature: __________________________________________ Date: ______________            

Why You Should Never Sign the Refusal to Vaccinate Form

According to the American Academy of Pediatrics (AAP), “within a 12-month period, 74% of pediatricians report encountering a parent who refused or delayed one or more vaccines.” [1]
In a letter to physicians, the AAP urged them to record vaccine refusals using a special document:
“The use of this or a similar form in concert with direct and non-condescending discussion can demonstrate the importance you place on appropriate immunizations, focuses parents’ attention on the unnecessary risk for which they are accepting responsibility, and may in some instances induce a wavering parent to accept your recommendations.”
If you are still deciding about the safety and effectiveness of vaccines, opting for a delayed vaccination schedule, or declining specific vaccines, your child’s health care provider may use this form in combination with your uncertainty to pressure you to vaccinate your child.
The form includes an admonition stating that the outcome of not vaccinating might include contracting:
“certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, meningitis, seizures, and deafness; other severe and permanent effects from these vaccine-preventable diseases are possible as well.”
These words may sound scary to parents who are newly researching the truth about vaccines, but informed parents know that adverse reactions to vaccines are much more likely to occur than contracting the diseases themselves.

The Refusal to Vaccinate Form May Be Used To Take Your Child Away From You

The suggested form provided to healthcare providers by the AAP, which you may be asked to read and sign, includes the following statements:
“I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others with whom my child might come into contact.”
Some parents and vaccine safety advocates have suggested child protective services or a parent in a custody battle may use this “admission” against the signing parent to remove a child from their care.
In a report published in Pediatrics, the AAP outlines how healthcare providers should respond when parents decline vaccinations for their children, stating that there are circumstances which would justify involving “the appropriate child protective services agency because of the concern about medical neglect.” [2]

The Refusal to Vaccinate Form May Be Used to Require Medical Treatment

The form also states:
“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 language suggests that your child may be treated medically against your wishes because you did not accept certain vaccines.

How to Respond to Your Child’s Health Care Provider When They Tell You To Sign the Refusal to Vaccinate Form

If your child’s doctor or nurse presents this form to you, you may simply remind them that you are not obligated to sign this form. Vaccine exemptions are available in all fifty states, and you have the right to use these exemptions to refuse vaccines without signing the “refusal to vaccinate” form. [3]
Patricia Finn, a national vaccine injury and exemption attorney located in New York City, says it is probably best to refuse to sign the form.
However, if your refusal to sign stands between you and an exemption, or you and your pediatrician, and you have a valid legal basis for an exemption to vaccinations, then you probably should sign the form because it is not a legally enforceable agreement against you.
According to Finn, signing a refusal form is not a waiver to rights to refuse vaccines, which are protected under statute and the United States Constitution. Simply stated, your rights to refuse vaccines would not be waived by the refusal form. It also would be unenforceable because the form would most likely have been signed under duress.
Another suggestion is to modify the form. You can cross out what you disagree with, initial it, and sign the form.
The rights of vaccine refusers were set out by the Supreme Court in the 1905 landmark vaccine-refusal case, Jacobson vs. Massachusetts.
Over one hundred years ago, the Justices of the Court recognized the potential for unnecessary vaccination mandates as being “a plain and palpable invasion of fundamental liberties,” like the new CDC refusal form you must sign to exercise your rights to refuse.
If you are faced with having to sign the form, remember the Supreme Court held in Jacobson in 1905 that only one vaccine was allowable, and only in an extreme circumstance in which a grave danger existed that “imperils society.”
The Supreme Court further held that vaccinations to be mandated must be necessary, proportional, non-discriminatory and harm avoidant, which today’s school required vaccines are not.
If you are presented with a refusal form from your child’s school or doctor, it would be wise to first consult with an attorney to obtain legal advice about how to proceed.


  1. https://www.aap.org
  2. http://pediatrics.aappublications.org
  3. http://www.nvic.org