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Print this declaration when an individual is requesting you, or someone you love, to take a vaccine,or submit to another medical intervention that you are choosing to refuse.

Complete the cover page by inserting the name & address of the person it is from (probably yourself), and then complete the recipient information, and date.

In the body of the letter, fill in this way:

I, (first name here) : (last name here) Family; respectfully require no vaccination be administered to myself or __(on this line place the name of your loved one, if it’s not you personally) _______ as it would be a violation…

Example:

I, John : Smith Family; respectfully require no vaccination be administered to myself or __my daughter, Princess Leah Smith _______ as it would be a violation…

In addition, print the attachment below, The Vaccine Liability Letter (Attachment C). Place this within the Refusal Declaration, following attachment B (page3) and before attachment D (page 4). This will expand the initial Declaration by 7 additional pages, for a document of 24 total pages. These can be used together or separately.