Vaccine Exemption Form - State Of Hawaii printable pdf download

Vaccine Exemption Form - State Of Hawaii

State of Hawaii Vaccine Exemption

Pursuant to:

Hawaii Administrative Rules §11-157-5

Hawaii Revised Statues §302A-1156, §302A-1157, §325-0034

I understand that all children are susceptible to diseases, even if they are vaccinated for

that particular disease. I understand that, according to the CDC vaccination does NOT

provide immunity, and therefore my child could contract the disease, even if vaccinated.

Furthermore, I understand that there is significant risk involved with vaccination and that

many children have become seriously injured, sometimes resulting in death, as a direct

result of the vaccination. VAERS (Vaccine Adverse Event Reporting System) was

specifically created by the government to handle the large number of people that have

died or received serious injury from vaccination.

I understand that some advocates of vaccination (usually ones with a vested financial

interest) report that vaccination can help prevent certain diseases. However, I do not

believe the reported benefits outweigh the confirmed danger and risks inherit with

vaccination.

If at any time there is, in the opinion of the Department of Health, danger of an outbreak

or epidemic from any communicable disease for which vaccination is required, this

exemption from vaccination shall not be recognized. As a result, my child will NOT be

vaccinated, but will be excluded from school until the threat of an epidemic is over.

VACCINE REFUSAL FORM

I,____________________________, as the parent, guardian or person in loco parentis of

(insert your name)

the child _________________________, do hereby certify that the administration of any

(insert your child’s name)

vaccine or other “so called” immunizing agents is contrary to our bona fide religious

tenets and practices and our personal beliefs. In Summary, I directly forbid any and all

parties, public or private, to administer any form of vaccination to my child.

This is pursuant to my right to refuse vaccination based on Hawaii State Law (see

attached: HRS

§302A-1156, §302A-1157, §325-0034 and HAR §11-157-5). Pursuant to Hawaii

statutes I am providing a copy of this statement to our child’s school administrator or operator of

the child’s group program.

Pupil’s Name:_________________________________

Date of Birth:______________

School:______________________________________

Grade:____________________

Parent/Guardian Name (print) :_____________________________________________________

Parent/Guardian Signature:________________________________________________________

Date:_________________________

Vaccine Exemption Form - State Of Hawaii