Tag Archives: #Nazi forced medical procedures

Liability Letter (PDF) parents can fill out & give to vaccine providers for them to sign so they can assume responsibility if your child gets sick from the vaccine.

It’s very important to include this notice of liability letter to take with you if you’re having your child vaccinated. Fill out your information in the letter and then REQUIRE the vaccine provider to sign it before your child is vaccinated. This document will ensure their liability and responsibility for any and all injuries or illnesses that may occur as a result of the toxic vaccine ingredients (see Vaccine Ingredients List on Previous Post). Hold your legal, medical, and educational professionals accountable; respectfully require them to take responsibility for their actions. Is this not what we teach our children?

Click here for a Liability Letter (PDF) parents can fill out & give to vaccine providers for them to sign so they can assume responsibility if your child gets sick from the vaccine.

Below is the letter in full:

“- AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY – – NOTICES AND CONDITIONAL ACCEPTANCE –

Herein the terms “administration” and “administrators” refers to all parties providing and/or “mandating” vaccine services and products including vaccine manufacturers, Distributors, Hospitals, Clinics, Physicians, Nurses, Government Agents and Agencies, Healthcare Providers and all other parties bringing vaccines to application or to market in any way.

This is agreement between the parties identified herein who on one hand, will receive vaccinations or be affected by the consequences of vaccination including the vaccinated party/s their guardians, representatives and all persons of common interests and, on the other hand, the administrators and providers of the vaccine/s in all the various capacities. Those parties are identified herein as:

Individual intended for Vaccination:____________________________________ Circle one: Adult Minor

Parents’ or Guardian’s Names and/or Head of Household: ____________________________________ Children’s names (all family members):____________________________________ __________________________________________________________________________________ Address:____________________________________ Phone:____________________________________

Other contacts if available:____________________________________

and Vaccine Administrators (below)

Authorized Officer of Vaccine Manufacturer, Name:____________________________________ Title:____________________________________ Address:____________________________________ Phone:____________________________________

Driver’s license number:____________________________________
Alternate contacts and identification:____________________________________

Authorized Officer of the Organization Administering Vaccinations, Name: ____________________________________

Page 1 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES

Title:____________________________________ Address:____________________________________ Phone:____________________________________
Driver’s license number:____________________________________
Alternate contacts and identification:____________________________________

Authorized and Accountable Officer of any “mandating” government agency, Name: ____________________________________ Title:____________________________________ Address:____________________________________ Phone:____________________________________

Driver’s license number:____________________________________
Alternate contacts and identification:____________________________________

Individual Administering the Vaccination to the Vaccine Recipients (Nurse, Healthcare Provider or Other, Name:____________________________________ Title:____________________________________ Address:____________________________________ Phone:____________________________________

Driver’s license number:____________________________________
Alternate contacts and identification:____________________________________
I hereby agree to and with the following stipulations, terms, declarations and positions:

1. I am aware and understand that vaccines are not a perfect or fully proven method of disease control.

Page 2 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES

2. I am aware and understand that vaccines are not 100% effective.

  1. I am aware that vaccines have not been tested enough to show that they are 100% safe and effective.
  2. I am aware and understand that vaccines can cause death or injury and disease which seriously and negatively affects the lives of vaccinated individuals, their families and their communities.
  3. I am aware and understand that vaccines, when causing disease and injury, can cause major costs to individuals, families and communities, which costs are solely the responsibility and liability of the causing agents which are the administrators and providers of a harming or ineffective vaccine.
  4. I am aware and understand that vaccines cause risk which is the sole responsibility of the administrators and providers of the vaccine.
  5. I am aware and understand that no one may be forced, coerced or compelled to accept medical treatment or foreign substances inserted into their bodies without full voluntary consent under full disclosure and that administering a treatment, harmful or otherwise, without consent of all affected parties is unlawful and unethical.
  6. I am aware and understand that vaccinations do, on occasion, cause harm, injury and disease including the disease they are intended to prevent.
  7. I am aware and understand that there are particular dangers and hazards of combining more than one vaccination in one or sequential administrations and some of those hazards and dangers are not well understood and have not been fully researched, tested or proven safe or effective.
  8. I understand that individuals have different physiologies and that a vaccination which may be harmless to one individual may be quite harmful to another individual.
  9. I am aware and understand that, prior to administration of any vaccination, administrators of vaccinations must and shall disclose to all interested parties all known and presumed risks, hazards, harm and failures of vaccinations and all contents of the proposed vaccination/s including all trace chemicals, adjuvants and components whether or not administrators consider those elements to be of consequence so that the recipients of vaccinations can make fully informed decisions with regard to accepting vaccination.
  10. I am aware and understand that administration of vaccinations without full disclosure and full voluntary consent of all interested parties and imposing risk and hazard in that way represents criminal violation, malpractice and major liability of the administrators of the vaccination to the vaccinated party/s should any negative consequences arise.
  11. I am aware and understand that any person who attempts to enforce a “mandate” in forcing or coercing vaccination or any other medical treatment upon any unwilling or uninformed party,

    Page 3 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES

whether or not that “mandate” is provided in law, codes or regulations, is personally fully liable for any and all harm, loss, damage, negative consequences of the vaccination upon the vaccinated party and all other interested parties. That liability extends to all administrators of that “mandate”, all legislators who were involved in the creation of that “mandate” and all companies and individuals who promoted that “mandate” through lobbying or other political action and all parties who participate in the enforcement of the “mandate”.

  1. I understand that, as an administrator or provider of any “mandated” vaccination I am assuming all liability, obligation and responsibility for any and all negative and/or unintended consequences of the administration of the vaccine and that I must “make whole” the recipients of the vaccine, their guardians, families and community for any and all financial and personal harm, damage and losses caused by the vaccine and any and all harm which may be reasonably attributed to the vaccine. I understand that this is necessary because laws to not adequately protect vaccine recipients and, in fact, put the public at risk of uninsured harm from vaccines.
  2. I am aware and understand that I must disclose all risks of vaccination prior to administration of the vaccine and, because vaccinations do pose risks, I must allow the recipients, guardians and families to refuse the vaccination at their sole discretion, and that disclosure of hazards and risks does not absolve me from any responsibility, liability or accountability for negative consequences of the vaccinations I administer.
  3. If a person suffers any disease or injury at any time after vaccination and not before vaccination and that disease or injury cannot be affirmatively attributed to any particular cause other than the vaccination, then I agree that it is reasonable to presume that the injury or disease was or may have been caused by the vaccination and I will so presume and accept that theory in the absence of compelling evidence to the contrary.
  4. If the vaccine recipients, guardians, family members and interested parties of the vaccinated party should, after the vaccination, submit claims for harm, loss, damages, injuries or disease which they reasonably suspect to be caused fully or partially by the vaccination, then the claims must and shall be paid and delivered by the administrators of the vaccination (above) to the claimant/s without challenge within 30 days from submission of each claim and any challenge to the claim/s must be made through formal written process and/or legal action. Requests for recovery of claims paid must be supported by fact, evidence, law and moral cause. Refusal or obstruction of service of claim shall not reduce obligations and shall be cause for escalated claim.
  5. I am aware and understand that all administrators of vaccinations are responsible for any emotional distress caused by their vaccinations and are liable for compensation for such emotional distress to the victim/s.
  6. Administrators of vaccinations hereby agree that they will allow and facilitate recording, videotaping, documentation and investigation of all services and processes they administer to the vaccine recipient and that administrators of vaccinations will not refuse or obstruct that information gathering for such reasons as “privacy” or “security”.

    Page 4 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES

  1. I am aware and understand that any failure or refusal to sign this agreement causes suspicion of intention to do harm to the vaccinated party and others and to avoid responsibility for potential harm that may be caused by vaccination, and I am aware and understand that failure or refusal of signature of this agreement by any administrator of vaccines is cause for rightful refusal of vaccination by the intended vaccination recipient with law, code, regulations, contracts and “mandates” notwithstanding.
  2. Any threat of consequence for refusal of vaccination/s, such as removal from school, quarantine, “child endangerment” etc. is coercion, is offensive, inappropriate, unlawful and violates parental rights. There is no law and can be no valid law which would rightfully grant authority over any individual to determine medical treatment for any other party who is in possession of their faculties. Refusal of vaccination does not in any way imply poor judgment, diminished capacities or social irresponsibility.
  3. I am / am not (circle one) claiming that I personally have the right and authority to force medical treatment and vaccinations upon the party (above) whom I intend for vaccination without his/her consent. If I claim that authority, then I will provide all legal and official reference which bestows that authority upon me specifically against the intended recipient of the vaccination, as authorized and consented by that recipient. I understand that I must provide evidence of authority to the satisfaction of all interested parties before the person intended for vaccination may be vaccinated because the interested parties presume that no such authority exists nor can exist, and, in many cases, the harm caused by vaccinations cannot be reversed.
  4. I understand and agree that the person intended for vaccination is not responsible to gather signatures on this form. The parties intending to vaccinate must acquire and share this form, sign it and deliver it in multiple copies to any party intended for vaccination upon request. At such time as the duly signed forms are delivered to the person intended for vaccination, those agreement forms will be signed by the person intended for vaccination or by his/her guardian and one copy will be returned to each administrator of the vaccination/s. If one of the requested administrators above fails to sign and return the form, all agreements are void and vaccination is rightfully refused.
  5. Refusal to sign this form is indication of deceit, bad faith and hypocrisy on the part of a vaccine administrator who may recommend vaccination as “safe”, but, at the same time, deny responsibility for the hazards. If vaccinations are “safe” then refusal or hesitation to sign this form is firm indication of misrepresentation with the assertion of “safety”.

NOTICE: If this form is refused or not signed by any vaccine administrators listed above, then refusal of vaccine is rightful and refusal must be presumed and honored. Vaccination does pose risks, therefore administration of vaccine without signature on this agreement by all parties called for herein or and/or without fully informed consent by all interested parties constitutes criminal assault, malpractice, intentional harm and violation of rights against the vaccinated parties and all other parties of common interest by the administrators and providers of the vaccine whether any harm is caused or not by the vaccination, therefore, without fully informed consent by all interested parties, major obligations and liabilities arise from non-consensual vaccination whether or not the vaccination causes physical injury or disease.

Page 5 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES

NOTICE: Refusal to sign this form constitutes admission and warning to the prospective recipient of vaccination that vaccination may cause harm and should be avoided in order to protect the health and safety of those receiving treatment. This is separate and distinct from any benefit/s or “necessities” that may be attributed to vaccinations and vaccination programs.

NOTICE: A separate agreement must be signed for each individual intended to be vaccinated. SIGNATURES OF THE AGREEING PARTIES
Individual intended to be Vaccinated:____________________________________
Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________ Date:____________________________________

Parents’ or Guardian’s Names and/or Head of Household (if different from above): ____________________________________
Print name:____________________________________ Date:____________________________________

Authorized Officer of Vaccine Manufacturer:

____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________ Date:____________________________________

Page 6 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES

Authorized Officer of the Organization (clinic, hospital or office) Administering Vaccinations: ____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________ Date:____________________________________

Individual Administering the Vaccination to the Vaccine Recipients (Nurse, Healthcare Provider or

Other), Name:____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________ Date:____________________________________

Authorized and Accountable Officer of any “mandating” government agency or program:

____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________ Date:____________________________________

Authorized Officer responsible for distributing the Vaccination to healthcare facilities and providers:

Page 7 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES

Name:____________________________________ Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________ Date:____________________________________

Page 8 of 8

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES”

Urgent: We Need People to Deliver These Papers to All Private Schools Especially Amish & Mennonite Ones!

Updated! – Letter of Liability Below for Vaccine Providers

Click to view this story on our podcast here on YouTube page don’t forget to subscribe and click that little bell to get our latest updates.

https://youtu.be/DZ2wZoTWtYI

We have the solution for the vaccine nightmare, at least for private schools: simply change your status to a homeschool co-op. Each parent can mail a very brief letter of intent to homeschool, a separate letter should be sent for each child. Keep the original for your records and mail a copy to the superintendent of the school district in your area. Because the Amish and Mennonites do not have the Internet or social media, we are making a particular effort to deliver copies of these papers to them personally. Please help all private schools preserve their way of life by transitioning into a homeschool co-op.

Click here to download the letter of intent (PDF) to homeschool.

Click here to download the flyer (PDF) that goes along with the letter.

NEW! – Click here for a Liability Letter (PDF) parents can fill out & give to vaccine providers for them to sign so they can assume responsibility if your child gets sick from the vaccine.

Click here to download the list of vaccine ingredients (PDF).

Remember to include all these documents in your package for the potential homeschooler. Thank you very much for helping us get these papers to as many parents as possible!

cropped-courtroomwatchlogo2Here’s the full text of the letter to homeschool, which you can print out by clicking on the PDF link above:

To:                                                                                                              Date:

Address:

From:

Address:

Notice of Intent to Homeschool

Greetings, this letter is notice that I, ___________________, intend to

homeschool my child, ____________________, for the upcoming/current school year

20_____-20_____, His/her grade will be _____;

Sincerely,

____________________________

 

cropped-courtroomwatchlogo2Here’s the full text of the vaccine info flyer, which you can print out by clicking the PDF link above:

Protect your children!

Change your private school to a ‘homeschool co-op’

Throughout New York state, county and state employees of the ‘health department’ are trespassing upon Amish and Mennonite private property attempting to force parents to submit their children to the needle, or else watch their private schools be forcibly shut down. Vaccines are NOT safe, and even if someone thinks they are, forcing them on others is NOT appropriate. It must be noted that the U.S. Court of Claims has awarded over 4.2 billion dollars to people injured by vaccines. This certainly indicates vaccines are NOT safe. It is dishonest for department employees to refuse to provide a full vaccine ingredients list, which identifies hundreds of harmful chemicals and pathogens present in vaccines. It is dishonest for the county and state employees to refuse to disclose that their pensions are heavily invested in the pharmaceutical corporations that make the vaccines they are pushing. It is also dishonest for county and state employees to refuse to inform you of the solution: simply start a homeschool co-op. As a private school the state demands forced vaccinations, with homeschooling they cannot. The letter provided here can be used, just write your name, address, child’s name and grade, and the year. Mail or hand deliver a letter to the superintendent of your local school district for each child you have. Protect your children! Start your homeschool co-op! For questions or comments call Eric at 585-730-9220. Learn more at courtroomwatch.com.

cropped-courtroomwatchlogo2Here’s the full text of the liability letter, which you can print out by clicking the PDF link above: 

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY
NOTICES AND CONDITIONAL ACCEPTANCE

Herein the terms “administration” and “administrators” refers to all parties providing and/or “mandating” vaccine services and products including vaccine manufacturers, Distributors, Hospitals, Clinics, Physicians, Nurses, Government Agents and Agencies, Healthcare Providers and all other parties bringing vaccines to application or to market in any way.

This is agreement between the parties identified herein who on one hand, will receive vaccinations or be affected by the consequences of vaccination including the vaccinated party/s their guardians, representatives and all persons of common interests and, on the other hand, the administrators and providers of the vaccine/s in all the various capacities. Those parties are identified herein as:

Individual intended for Vaccination:____________________________________
Circle one: Adult Minor

Parents’ or Guardian’s Names and/or Head of Household: ____________________________________

Children’s names (all family members):____________________________________

__________________________________________________________________________________

Address:____________________________________

Phone:____________________________________

Other contacts if available:____________________________________

and Vaccine Administrators (below)

Authorized Officer of Vaccine Manufacturer, Name:____________________________________

Title:____________________________________
Address:____________________________________
Phone:____________________________________

Driver’s license number:____________________________________

Alternate contacts and identification:____________________________________

Authorized Officer of the Organization Administering Vaccinations, Name:

____________________________________

Title:____________________________________

Address:____________________________________
Phone:____________________________________

Driver’s license number:____________________________________

Alternate contacts and identification:____________________________________

Authorized and Accountable Officer of any “mandating” government agency, Name:

____________________________________

Title:____________________________________
Address:____________________________________

Phone:____________________________________

Driver’s license number:____________________________________

Alternate contacts and identification:____________________________________

Individual Administering the Vaccination to the Vaccine Recipients (Nurse, Healthcare Provider or

Other, Name:____________________________________

Title:____________________________________

Address:____________________________________
Phone:____________________________________

Driver’s license number:____________________________________

Alternate contacts and identification:____________________________________

I hereby agree to and with the following stipulations, terms, declarations and positions:

  1. I am aware and understand that vaccines are not a perfect or fully proven method of disease control.
  2. I am aware and understand that vaccines are not 100% effective.
  3. I am aware that vaccines have not been tested enough to show that they are 100% safe and effective.
  4. I am aware and understand that vaccines can cause death or injury and disease which seriously and negatively affects the lives of vaccinated individuals, their families and their communities.
  5. I am aware and understand that vaccines, when causing disease and injury, can cause major costs to individuals, families and communities, which costs are solely the responsibility and liability of the causing agents which are the administrators and providers of a harming or ineffective vaccine.
  6. I am aware and understand that vaccines cause risk which is the sole responsibility of the administrators and providers of the vaccine.
  7. I am aware and understand that no one may be forced, coerced or compelled to accept medical treatment or foreign substances inserted into their bodies without full voluntary consent under full disclosure and that administering a treatment, harmful or otherwise, without consent of all affected parties is unlawful and unethical.
  8. I am aware and understand that vaccinations do, on occasion, cause harm, injury and disease including the disease they are intended to prevent.
  9. I am aware and understand that there are particular dangers and hazards of combining more than one vaccination in one or sequential administrations and some of those hazards and dangers are not well understood and have not been fully researched, tested or proven safe or effective.
  10. I understand that individuals have different physiologies and that a vaccination which may be harmless to one individual may be quite harmful to another individual.
  11. I am aware and understand that, prior to administration of any vaccination, administrators of vaccinations must and shall disclose to all interested parties all known and presumed risks, hazards, harm and failures of vaccinations and all contents of the proposed vaccination/s including all trace chemicals, adjuvants and components whether or not administrators consider those elements to be of consequence so that the recipients of vaccinations can make fully informed decisions with regard to accepting vaccination.
  12. I am aware and understand that administration of vaccinations without full disclosure and full voluntary consent of all interested parties and imposing risk and hazard in that way represents criminal violation, malpractice and major liability of the administrators of the vaccination to the vaccinated party/s should any negative consequences arise.
  13. I am aware and understand that any person who attempts to enforce a “mandate” in forcing or coercing vaccination or any other medical treatment upon any unwilling or uninformed party, whether or not that “mandate” is provided in law, codes or regulations, is personally fully liable for any and all harm, loss, damage, negative consequences of the vaccination upon the vaccinated party and all other interested parties. That liability extends to all administrators of that “mandate”, all legislators who were involved in the creation of that “mandate” and all companies and individuals who promoted that “mandate” through lobbying or other political action and all parties who participate in the enforcement of the “mandate”.
  14. I understand that, as an administrator or provider of any “mandated” vaccination I am assuming all liability, obligation and responsibility for any and all negative and/or unintended consequences of the administration of the vaccine and that I must “make whole” the recipients of the vaccine, their guardians, families and community for any and all financial and personal harm, damage and losses caused by the vaccine and any and all harm which may be reasonably attributed to the vaccine. I understand that this is necessary because laws to not adequately protect vaccine recipients and, in fact, put the public at risk of uninsured harm from vaccines.
  15. I am aware and understand that I must disclose all risks of vaccination prior to administration of the vaccine and, because vaccinations do pose risks, I must allow the recipients, guardians and families to refuse the vaccination at their sole discretion, and that disclosure of hazards and risks does not absolve me from any responsibility, liability or accountability for negative consequences of the vaccinations I administer.
  16. If a person suffers any disease or injury at any time after vaccination and not before vaccination and that disease or injury cannot be affirmatively attributed to any particular cause other than the vaccination, then I agree that it is reasonable to presume that the injury or disease was or may have been caused by the vaccination and I will so presume and accept that theory in the absence of compelling evidence to the contrary.
  17. If the vaccine recipients, guardians, family members and interested parties of the vaccinated party should, after the vaccination, submit claims for harm, loss, damages, injuries or disease which they reasonably suspect to be caused fully or partially by the vaccination, then the claims must and shall be paid and delivered by the administrators of the vaccination (above) to the claimant/s without challenge within 30 days from submission of each claim and any challenge to the claim/s must be made through formal written process and/or legal action. Requests for recovery of claims paid must be supported by fact, evidence, law and moral cause. Refusal or obstruction of service of claim shall not reduce obligations and shall be cause for escalated claim.
  18. I am aware and understand that all administrators of vaccinations are responsible for any emotional distress caused by their vaccinations and are liable for compensation for such emotional distress to the victim/s.
  19. Administrators of vaccinations hereby agree that they will allow and facilitate recording, videotaping, documentation and investigation of all services and processes they administer to the vaccine recipient and that administrators of vaccinations will not refuse or obstruct that information gathering for such reasons as “privacy” or “security”.
  20. I am aware and understand that any failure or refusal to sign this agreement causes suspicion of intention to do harm to the vaccinated party and others and to avoid responsibility for potential harm that may be caused by vaccination, and I am aware and understand that failure or refusal of signature of this agreement by any administrator of vaccines is cause for rightful refusal of vaccination by the intended vaccination recipient with law, code, regulations, contracts and “mandates” notwithstanding.
  21. Any threat of consequence for refusal of vaccination/s, such as removal from school, quarantine, “child endangerment” etc. is coercion, is offensive, inappropriate, unlawful and violates parental rights. There is no law and can be no valid law which would rightfully grant authority over any individual to determine medical treatment for any other party who is in possession of their faculties. Refusal of vaccination does not in any way imply poor judgment, diminished capacities or social irresponsibility.
  22. I am / am not (circle one) claiming that I personally have the right and authority to force medical treatment and vaccinations upon the party (above) whom I intend for vaccination without his/her consent. If I claim that authority, then I will provide all legal and official reference which bestows that authority upon me specifically against the intended recipient of the vaccination, as authorized and consented by that recipient. I understand that I must provide evidence of authority to the satisfaction of all interested parties before the person intended for vaccination may be vaccinated because the interested parties presume that no such authority exists nor can exist, and, in many cases, the harm caused by vaccinations cannot be reversed.
  23. I understand and agree that the person intended for vaccination is not responsible to gather signatures on this form. The parties intending to vaccinate must acquire and share this form, sign it and deliver it in multiple copies to any party intended for vaccination upon request. At such time as the duly signed forms are delivered to the person intended for vaccination, those agreement forms will be signed by the person intended for vaccination or by his/her guardian and one copy will be returned to each administrator of the vaccination/s. If one of the requested administrators above fails to sign and return the form, all agreements are void and vaccination is rightfully refused.
  24. Refusal to sign this form is indication of deceit, bad faith and hypocrisy on the part of a vaccine administrator who may recommend vaccination as “safe”, but, at the same time, deny responsibility for the hazards. If vaccinations are “safe” then refusal or hesitation to sign this form is firm indication of misrepresentation with the assertion of “safety”.

NOTICE: If this form is refused or not signed by any vaccine administrators listed above, then refusal of vaccine is rightful and refusal must be presumed and honored. Vaccination does pose risks, therefore administration of vaccine without signature on this agreement by all parties called for herein or and/or without fully informed consent by all interested parties constitutes criminal assault, malpractice, intentional harm and violation of rights against the vaccinated parties and all other parties of common interest by the administrators and providers of the vaccine whether any harm is caused or not by the vaccination, therefore, without fully informed consent by all interested parties, major obligations and liabilities arise from non-consensual vaccination whether or not the vaccination causes physical injury or disease.

NOTICE: Refusal to sign this form constitutes admission and warning to the prospective recipient of vaccination that vaccination may cause harm and should be avoided in order to protect the health and safety of those receiving treatment. This is separate and distinct from any benefit/s or “necessities” that may be attributed to vaccinations and vaccination programs.

NOTICE: A separate agreement must be signed for each individual intended to be vaccinated.

SIGNATURES OF THE AGREEING PARTIES

Individual intended to be Vaccinated:____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________

Date:____________________________________

Parents’ or Guardian’s Names and/or Head of Household (if different from above):

____________________________________

Print name:____________________________________
Date:____________________________________

Authorized Officer of Vaccine Manufacturer:
____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________

Date:____________________________________

Authorized Officer of the Organization (clinic, hospital or office) Administering Vaccinations:
____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________

Date:____________________________________

Individual Administering the Vaccination to the Vaccine Recipients (Nurse, Healthcare Provider or

Other), Name:____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________

Date:____________________________________

Authorized and Accountable Officer of any “mandating” government agency or program:
____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________

Date:____________________________________

Authorized Officer responsible for distributing the Vaccination to healthcare facilities and providers:

Name:____________________________________

Print name:____________________________________

Direct Contact information: _________________________________________________________________________

_________________________________________________________________________________

Date:____________________________________