I, ______________________________________________, [insert full name]
hereby certify that I am the parent or legal guardian of:
_______________________________________________. [insert full name of child]
I hereby swear to personally be held legally responsible and financially liable for:
1. Any physical harm, bodily injury, or any mental anguish or harm that may occur to any other person (adult or child) if my unvaccinated child* should transmit a recognised vaccine-preventable infection to that person;
2. Any physical harm, bodily injury, or any mental anguish or harm that may occur to any other persons who contract the infection through further contact with persons infected by my child;
3. Any consequent costs incurred in the Public Health response to contain any ongoing outbreaks or epidemics of disease that directly relate to the initial transmission of a vaccine-preventable infection from my child.
*This proviso shall apply to any child who, as a result of the deliberate intent of a parent or guardian, has not been vaccinated according to the recommended infant and childhood vaccination schedules (as laid down by the Centers for Disease Control and Prevention based upon current recommendation of the Advisory Committee on Immunization Practices) for reasons of a non-medical exemption (religious, philosophical, moral, ideological or conscientious objection).
I hereby waive any statutory, Common Law, Constitutional, UCC, international treaty, and any other legal immunities from liability lawsuits.
I understand that my unvaccinated child will only be accepted into a daycare, childcare, school or other educational facility if this liability form is completed by me and signed with a legally valid signature.
I certify that I am the parent or guardian of the child named on this form.
My name: ________________________________________
Signature: ________________________________________
Date: ________________________________________
Address: ________________________________________
________________________________________
Child’s name: ________________________________________
Date of birth: ________________________________________
Address: ________________________________________
________________________________________
autisticagainstantivaxxers
Legal liability form for vaccine refusal
I, ______________________________________________, [insert full name]
hereby certify that I am the parent or legal guardian of:
_______________________________________________. [insert full name of child]
I hereby swear to personally be held legally responsible and financially liable for:
1. Any physical harm, bodily injury, or any mental anguish or harm that may occur to any other person (adult or child) if my unvaccinated child* should transmit a recognised vaccine-preventable infection to that person;
2. Any physical harm, bodily injury, or any mental anguish or harm that may occur to any other persons who contract the infection through further contact with persons infected by my child;
3. Any consequent costs incurred in the Public Health response to contain any ongoing outbreaks or epidemics of disease that directly relate to the initial transmission of a vaccine-preventable infection from my child.
*This proviso shall apply to any child who, as a result of the deliberate intent of a parent or guardian, has not been vaccinated according to the recommended infant and childhood vaccination schedules (as laid down by the Centers for Disease Control and Prevention based upon current recommendation of the Advisory Committee on Immunization Practices) for reasons of a non-medical exemption (religious, philosophical, moral, ideological or conscientious objection).
I hereby waive any statutory, Common Law, Constitutional, UCC, international treaty, and any other legal immunities from liability lawsuits.
I understand that my unvaccinated child will only be accepted into a daycare, childcare, school or other educational facility if this liability form is completed by me and signed with a legally valid signature.
I certify that I am the parent or guardian of the child named on this form.
My name: ________________________________________
Signature: ________________________________________
Date: ________________________________________
Address: ________________________________________
________________________________________
Child’s name: ________________________________________
Date of birth: ________________________________________
Address: ________________________________________
________________________________________
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