Example Religious Affidavit - Mothering Forums
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#1 of 3 Old 11-02-2004, 07:03 PM - Thread Starter
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Here is an example of a religious exemption I made up a few months ago. This one uses the Georgia Code as an example.

An Example Affidavit

-First copy & paste the code from your state. Example follows:

[Education, Part III, Health, Ga. Code Ann. 20-2-771. Rules of Department of Human Resources Public Health, Ga. Comp. R. & Regs.§ 290-5-4-. 01 to .09.]

-Then copy & paste the section that pertains to religious exemption. Example:

[A child may be exempted on religious grounds if a parent furnishes an affidavit swearing that the immunization required conflicts with the religious beliefs of the parent. The immunization may be required in cases when such disease is in epidemic stages. GCA § 20-2-771(e). Religious belief in divine healing through faith not to excuse refusal to have children vaccinated. son v. State, 84 Ga. App. 259, 65 S.E. 2d 848 (1951).]

-Then continue with the following:

Pursuant to the aforementioned (insert above code), I, the undersigned, declare the immunization requirements as set forth in ( insert same code) contrary to my bona fide religious beliefs and request, as permitted by the law, an exemption from the immunization requirements of your institution for myself or the undersigned minor child under my legal care or guardianship.

NAME ______________________________________






___ Check here if declaring exemption for a minor child and enter child's name below.

MINOR CHILD'S NAME _________________________________________





**A nice, professional looking affidavit. BTW, they are not allowed to ask your religion.


**This can be copied to Wordpad & edited to your needs.
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#2 of 3 Old 11-02-2004, 07:12 PM
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Thanks for the template!!!
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#3 of 3 Old 11-02-2004, 08:30 PM
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I love that template. Very professional looking.

Missouri has an index card that I picked up at the health department. I am supposing I need to file it with someone....but have kept them for my personal files. I got a couple of funny looks when I requested "religious exemption immunization cards" but they were handed over with no fuss. I was picking some up for a friend as well so I needed five cards. Maybe it was the total amount of cards that got me the funny look to begin with.
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