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Vaccine Exemption Example Letter

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February 5, 2013 in Health


Below is the vaccine exemption form I currently have for my children. Obviously you will need to import your state’s specific law, and a link to where you can find those is listed below. I hope this helps.


I, (parent name here), mother(or father or simply parent) of (Child’s name here), born (Child’s birth date here) hereby state that I have chosen not to participate in any and all vaccination programs for my child, including those not yet available. (Child’s name here) does not participate in vaccination programs due to our strong moral and ethical objections to vaccines. I maintain that this is a reasonable, justifiable, ethical decision made to protect and maintain my child’s health. I base this belief on the following reasons:

  • Vaccines are a medical intervention needlessly performed on a healthy child 
  • Vaccines can result in injury and/or death of a healthy child 
  • Vaccines deliberately introduce killed or live microorganisms into a healthy child’s body; and there is no guarantee that this action will not compromise the health of the child. There is also no guarantee that this action will not cause the death of the child, either immediately or in the future. 
  • Vaccines are not guaranteed to protect a child from contracting an illnes 
  • Vaccines lack the adequate scientific knowledge regarding the way they act in the human body at a cellular or molecular level – either in a single dose or combination doses. 
  • Vaccines contain known toxins and carcinogens

Because of these reasons I believe that any and all vaccines are a medical procedure that can be reasonably be considered experimental each and every time they are injected into a healthy child. According to Pennsylvania State Law PA 28§ 23.84, my child “need not be immunized if the parent, guardian, or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical convictions similar to religious belief.”

I accept full responsibility for the health of my child, and because of my strong moral and ethical convictions, do not wish for my child to participate in any vaccination programs.


(add signature to bottom with date. Note that this should be notarized)


If you have multiple children, you need an exemption form for each child. They must have their own forms. You can certainly use the same form for each child but if they need their own, separate forms. If you aren’t in PA, then you need to put your own states laws in there. If you are using this for children in day care or schooling, you may need to add an additional paragraph stating that you understand your child will be excluded from activities in the event of an outbreak. Some families use that paragraph and some families do not. I personally feel that adding that paragraph is stating that your child is either at risk or putting others at risk simply due to their non-vaccinated status, which, contrary to popular belief, is not synonymous with non-immunized. Plenty of children – and adults – are naturally immunized without ever receiving a vaccine. It’s also giving the facility power. What defines an “outbreak”? Is one child coming in with a pox enough to exclude your child? Is a child with a sibling having a pox enough? Adding that last paragraph is something you need to sit down and think about.

Lastly, you may want to have both parents sign this form. Again, that’s up to the family. And you will want multiple copies of these forms. I keep a copy in my house and I keep one on me at all times. Their father also keeps a copy on him and my dad keeps a copy with him, just in case. (If their dad’s parents lived here, they would have a copy as well.) Anyone who ever cares for your children, be it a neighbour or a cousin, should keep a copy with them. You never know what may happen.

Please note, this is by no means the only way to write an exemption letter. This is simply what I have written based on example letters.

Vaccine exemption laws by state: http://www.ncsl.org/issues-research/health/school-immunization-exemption-state-laws.aspx

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