Vaccine Exemption Form & Complete Refusal Statement

Simply, I refuse to have toxic/carcinogenic/deadly substance(s)

injected directly into my bloodstream; specifically heavy metal
Mercury (Hg) (Thimiserol), Aluminum, unlicensed animal
Squalene, embryonic fetal tissue, oral or nasal viruses, epidermal
patches - or any other way that live or semi-live bacterium, virus,
pathogens, germs, or any other microorganisms that could have
been introduced into or upon my body; nor my children. I refuse
any animal or foreign DNA or RNA segments into my body
by “Big Pharma” or the Corporate Military Complex. Any
denial, detainment, or abuse contrary to this will result in a law suit entered in my family name against
all those who would be involved; any low-level person, the President, to the Rockefeller-led cartel.

I have the absolute right and freedom to Self-Shield and Self-Quarantine in my home against any such
pandemic outbreak(s). I take care of my own immune system and keep it strong with plenty of healthy
eating, proper hygiene, and Vitamin D3, Selenium, Zinc and Silver hydrosol supplements.

Lastly, I _______________________ (official signature), am proclaiming and exercising my First

Amendment Civil Right (that of freedom of speech) and 77.ILLADM.CODE 694.210 (Religious/
Spiritual Exemption from Vaccination & Testing). { Note to signatory – you may cross out the Illinois
exemption code and write in the statutory code for your respective state, for each of the 50 US states. }

(posted September 2009 on www.docstoc.com & www.scribd.com & fluscam.com for widespead use.)
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Vaccine Exemption Form & Complete Refusal Statement

Simply, I refuse to have toxic/carcinogenic/deadly substance(s)

injected directly into my bloodstream; specifically heavy metal
Mercury (Hg) (Thimiserol), Aluminum, unlicensed animal
Squalene, embryonic fetal tissue, oral or nasal viruses, epidermal
patches - or any other way that live or semi-live bacterium, virus,
pathogens, germs, or any other microorganisms that could have
been introduced into or upon my body; nor my children. I refuse
any animal or foreign DNA or RNA segments into my body
by “Big Pharma” or the Corporate Military Complex. Any
denial, detainment, or abuse contrary to this will result in a law suit entered in my family name against
all those who would be involved; any low-level person, the President, to the Rockefeller-led cartel.

I have the absolute right and freedom to Self-Shield and Self-Quarantine in my home against any such
pandemic outbreak(s). I take care of my own immune system and keep it strong with plenty of healthy
eating, proper hygiene, and Vitamin D3, Selenium, Zinc and Silver hydrosol supplements.

Lastly, I _______________________ (official signature), am proclaiming and exercising my First

Amendment Civil Right (that of freedom of speech) and 77.ILLADM.CODE 694.210 (Religious/
Spiritual Exemption from Vaccination & Testing). { Note to signatory – you may cross out the Illinois
exemption code and write in the statutory code for your respective state, for each of the 50 US states. }

(posted September 2009 on www.docstoc.com & www.scribd.com & fluscam.com for widespead use.)