As traditional school schedules resume in the coming days, many parents are bringing their children to their health care providers for sports physicals and well-child visits.

If you decline vaccines for your child, your child’s doctor may ask or even insist that you sign a refusal form stating you were offered information about vaccines and you opted out of one or more vaccinations.

This piece of paper may seem harmless, but there are important reasons to decline signing this form when you decline vaccines. Read on to learn why you should never sign this vaccine refusal form.

The Refusal Form From The AAP May Be Used To Scare You

By Missy Fluegge,

According to the American Academy of Pediatrics (AAP), “within a 12-month period, 74% of pediatricians report encountering a parent who refused or delayed one or more vaccines.” [1]

In a letter to physicians, the AAP urged them to record vaccine refusals using a special document:

“The use of this or a similar form in concert with direct and non-condescending discussion can demonstrate the importance you place on appropriate immunizations, focuses parents’ attention on the unnecessary risk for which they are accepting responsibility, and may in some instances induce a wavering parent to accept your recommendations.”

If you are still deciding about the safety and effectiveness of vaccines, opting for a delayed vaccination schedule, or declining specific vaccines, your child’s health care provider may use this form in combination with your uncertainty to pressure you to vaccinate your child.

The form includes an admonition stating that the outcome of not vaccinating might include contracting:

“certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, meningitis, seizures, and deafness; other severe and permanent effects from these vaccine-preventable diseases are possible as well.”

These words may sound scary to parents who are newly researching the truth about vaccines, but informed parents know that adverse reactions to vaccines are much more likely to occur than contracting the diseases themselves.

The Refusal To Vaccinate Form May Be Used To Take Your Child Away From You

The suggested form provided to healthcare providers by the AAP, which you may be asked to read and sign, includes the following statements:

“I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others with whom my child might come into contact.”

Some parents and vaccine safety advocates have suggested child protective services or a parent in a custody battle may use this “admission” against the signing parent to remove a child from their care.

In a report published in Pediatrics, the AAP outlines how healthcare providers should respond when parents decline vaccinations for their children, stating that there are circumstances which would justify involving “the appropriate child protective services agency because of the concern about medical neglect.” [2]

The Refusal To Vaccinate Form May Be Used To Require Medical Treatment

The form also states:

“I therefore agree to tell all health care professionals in all settings what vaccines my child has not received because he or she may need to be isolated or may require immediate medical evaluation and tests that might not be necessary if my child had been vaccinated.”

This language suggests that your child may be treated medically against your wishes because you did not accept certain vaccines.

How To Respond To Your Child’s Health Care Provider When They Tell You To Sign The Refusal To Vaccinate Form

If your child’s doctor or nurse presents this form to you, you may simply remind them that you are not obligated to sign this form. Vaccine exemptions are available in all fifty states, and you have the right to use these exemptions to refuse vaccines without signing the “refusal to vaccinate” form. [3]

Patricia Finn, a national vaccine injury and exemption attorney located in New York City, says it is probably best to refuse to sign the form.

However, if your refusal to sign stands between you and an exemption, or you and your pediatrician, and you have a valid legal basis for an exemption to vaccinations, then you probably should sign the form because it is not a legally enforceable agreement against you.

According to Finn, signing a refusal form is not a waiver to rights to refuse vaccines, which are protected under statute and the United States Constitution. Simply stated, your rights to refuse vaccines would not be waived by the refusal form. It also would be unenforceable because the form would most likely have been signed under duress.

Another suggestion is to modify the form. You can cross out what you disagree with, initial it, and sign the form.

The rights of vaccine refusers were set out by the Supreme Court in the 1905 landmark vaccine-refusal case, Jacobson vs. Massachusetts.

Over one hundred years ago, the Justices of the Court recognized the potential for unnecessary vaccination mandates as being “a plain and palpable invasion of fundamental liberties,” like the new CDC refusal form you must sign to exercise your rights to refuse.

If you are faced with having to sign the form, remember the Supreme Court held in Jacobson in 1905 that only one vaccine was allowable, and only in an extreme circumstance in which a grave danger existed that “imperils society.”

The Supreme Court further held that vaccinations to be mandated must be necessary, proportional, non-discriminatory and harm avoidant, which today’s school required vaccines are not.

If you are presented with a refusal form from your child’s school or doctor, it would be wise to first consult with an attorney to obtain legal advice about how to proceed.


These refusal to vaccinate forms were created to increase vaccination rates, scare parents, and potentially take children away from parents who decline vaccines or mandate medical treatment. Parents should refuse to sign these forms.

Has your child’s health care provider asked you to sign a refusal to vaccinate form? How did you respond? Please share your experiences in the comments section below. You can help other parents by sharing this article on social media.

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  1. Reported in January-February 2010 NEXUS Magazine, a New Times – Source Report of September 2009
    ( Government and pharmaceutical companies are depending upon our lack of knowledge of this fact. Stand your ground, say NO and use the form below:

    “A preliminary injunction to stop mandatory vaccinations has been issued in the United States District Court of New Jersey. This comes after a federal lawsuit opposing forced vaccinations was filed in the court by Tim Vawter, pro se Attorney, on 31 July with the federal government as defendant. Vawter’s filing included a Complaint and several pages of evidentiary Exhibits. His legal papers have been written not only for filing in federal court, but so they can be looked at by activists around the world for ideas on filing lawsuits in their countries to help stop forced vaccinations. The Preliminary Injunction immediately halts mandatory vaccinations in the United States.

    WEBSITES: (re. squalene, military created vaccine for anthrax that is an additive in the flu, etc. vaccines and is toxic) (vaccines assault against humanity)

    BOOK: Raising a Vaccine-free Child, by Wendy Lydall (It’s being done by caring and self-determining women.)

    – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –

    FORM: (One form for each child or adult.

    In light of the ruling of U.S. Judge in U.S. District Court of New Jersey and the resulting injunction against the federal government, to stop mandatory vaccinations in any state by anyone, as reported by CNN Report 29 September 2009, I hereby notify you that I am exercising my Constitutional Right to refuse vaccination, of any kind, for any reason, for the following individual:

    _________________________________________(child/adult’s name)

    __________________________________________(parent or guardian’s name)

    ___________________ (signed)


    (Law Suit was originally by filed by Tim Vawter, pro se Attorney on July 31, 2009 against the government in the U.S. District Court of New Jersey and is available for review for anyone.)


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