I've seen a few examples but I'm looking for a very basic ("PC" almost) statement for both religious and philosophical reasons. For the exemption form I'm looking at you can check boxes: medical, religious, philosophical. For the religious it ask your religion- which I didn't think you had to list (I'm in Ohio) and under philosophical it says please explain. Just looking for what others are doing. Thank you.
Ohio law: http://codes.ohio.gov/orc/3313.671 "A pupil who presents a written statement of the pupil’s parent or guardian in which the parent or guardian declines to have the pupil immunized for reasons of conscience, including religious convictions, is not required to be immunized."
I wouldn't use the form, which is not required by law. I would write this on a separate paper:
To Whom it May Concern:
I decline to have my child vaccinated for reasons of conscience.
I might also print out the law and highlight the part that I quoted above, and give it to them along with my written statement.