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Immunization affidavit

Affidavit vaccination form 2026

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The document is an affidavit declaring the affiant's religious convictions against vaccinations for their child. It states that the affiant, a parent or guardian, believes that any form of vaccination or medical procedure involving foreign substances contradicts their deeply held religious beliefs. The affidavit seeks to exempt the child from immunizations and related medical practices based on these convictions.

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Click ‘Get Form’ to open the affidavit vaccination form in the editor.
Begin by filling in the STATE and COUNTY at the top of the form. This information is essential for legal validity.
In the first section, enter your name as the Affiant, ensuring it matches your identification documents.
Specify your relationship to the child by selecting 'Mother', 'Father', or 'Guardian' in the designated field.
Clearly state your child's name in the provided space, as this identifies who is being exempted from vaccinations.
In section two, articulate your religious convictions against vaccinations. Feel free to elaborate on your beliefs if necessary.
Complete section three by affirming that this affidavit serves to exempt your child from immunizations due to your religious beliefs.
Finally, print your name and sign where indicated. Ensure you have a notary public witness your signature for authenticity.

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How to write an exemption letter?

How do we write an exemption letter? Create a letterhead or heading. Write the inside address. Use a formal salutation or greeting. Start the body with a statement of purpose. Use a legal or any other valid reference. Include enclosure information (if any). Provide contact information.

How to write a permission letter for vaccination?

I hereby request and authorize the patient named above to receive a Pfizer-BioNTech COVID-19 vaccine from Vaccination Site, and further receive any and all health care services available from and deemed necessary by the staff of the vaccination site in the event of an adverse reaction

How to document vaccine refusal?

For parents who refuse one or more recommended immunizations, document your conversation, the provision of the VIS(s), and have the parent sign the vaccine refusal form and keep the form in the patients medical record.

How to get a vaccine exemption in Pennsylvania?

A record from a healthcare providers medical record system (including a patient portal) that is either a: Vaccine Administration Record from the facility where the vaccine was administered that includes the: Vaccine administered.

How do I write a vaccination exemption letter?

Please initial next to each of the statements below: I request a reasonable accommodation due to my sincere religious beliefs. I understand and assume the risks of non-vaccination. I accept full responsibility for my health, thus removing liability from the City to the required vaccinations.

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