AFFIDAVIT

I/We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s)
of the Kansas Republic affirm: Be it known to all courts, governments, and other parties that:

Being (a person/people) of Strong Christian Morals, it is against (my/our) Deep, Sincerely Held, Religious
Convictions to accept the injection of any foreign substance into (my Body/our Bodies) or the Body of (my/our)
(Child/Children). This includes, but is not limited to, any and all, Vaccinations, Shots, Tests for Diseases, Oral
Vaccines, Epidermal Patches and in any other way that Live or Killed Bacterium, Viruses, Pathogens, Germs,
or any other Microorganisms, may be introduced into or upon my body or any of my children’s bodies.

This written statement to exempt (my/our) child from any immunizations, TB testing, and other shots/injections,
because (I/we) hold genuine and sincere personal religious beliefs which are inconsistent with these medical
procedures and experimentation. The practice of vaccination and the injection of any foreign substance is
contrary to (my/our) conscientiously held religious beliefs and practices, and violates the free exercise of
(my/our) religious principles.

The attenuated virus used to produce the Rubella vaccine (RA27/3) was obtained from an aborted fetus and
then cultivated on fetal tissue from another aborted baby (WI-38) and is also in the rubella portion of the MMR-
II vaccine. The Chickenpox vaccine containing WI-38, MRC-5 and Hepatitis-A vaccine (MRC-5) were
obtained from human babies that were electively aborted. A conflict arises because (my/our) religious
convictions are predicated on the belief that all life is sacred. God's commandment "Thou Shall Not Kill"
applies to the practice of abortion. The acceptance of these vaccines promotes abortion and violates the Sixth
Commandment of "Thou Shall Not Kill". The Hepatitis-B vaccine supposedly protects against a disease that is
only transmitted through multiple sexual partners or street IV drug users and therefore usurps (my/our) parental
authority to condemn such activity in (my/our) child. The acceptance of this vaccine promotes sexual
promiscuity and immoral behavior in direct contradiction to the teachings of (my/our) faith.

(We / I) {First and Last name(s)}, as the {(parent (s) / guardian(s)}of _________________________(name of
child) are/am exercising (our/my) rights under the First Amendment of the US Constitution and Kansas law
KSA 72-5209 (b) (2) to receive Religious Exemption from Vaccination.

Applicable law has been interpreted to mean that a religious belief is subject to protection even though no
religious group espouses such beliefs or the fact that the religious group to which the individual professes to
belong may not advocate or require such belief. Title VII of the Civil Rights Act of 1964 as amended Nov. 1,
1980; Part 1605.1-Guidelines on Discrimination Because of Religion.

Our legal rights are guaranteed by the free exercise clause of the First Amendment to the U.S. Constitution.
Recent court decisions have upheld the rights of individuals seeking exemptions from immunizations based
upon personal and religious reasons. On the U.S. Supreme Court level in Frazee V. Illinois Dept. of Security,
489 U.S. 829, it was found that a state may not deny an exemption simply because a person is not a member of
a formal religious organization.

The Lord Jesus Christ and Our Creator Yahweh are the only source of protection of (my body/our bodies) and
that of (my/our) family that (I/we) can accept..

(I/We) affirm that vaccination & injections of any foreign substances and proteins conflict with (my/our)
religious beliefs as stated above. Therefore, (I/we) would request that you accommodate (my/our) religious
beliefs and practices by exempting (my/our) child from any vaccinations, injections and testing of any kind.

Rest assured that (my family and I/our family) do practice a form of immunization that keeps our immune
systems strong and is in keeping with Biblical principles.
Further Affiant Saith Not

The use of notary below is for identification only, and such use does NOT grant any jurisdiction to anyone.

Subscribed and sworn, without prejudice, and with all rights reserved, (Print Name Below)

_______________________________________________________________,
Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.

_______________________________
Signature of Affiant

ACKNOWLEDGMENT

state of Kansas

county of _________________:

On this _______ day of ______________, 200___, before me

personally appeared __________________________________, to me known to be the person described in and

who executed the foregoing instrument and acknowledged that he executed the same as his free act and deed,
for the purposes therein set forth.

_______________________________________
(Notary Public)

My Commission Expires ______________________________, 200___

K.S.A. § 65-508

(2) a written statement signed by a parent or guardian that the parent or guardian is an adherent of a religious
denomination whose teachings are opposed to immunizations.

K.S.A. § 65-519

(2) The immunization requirement of subsection (c)(1) shall not apply if one of the following is obtained:

(A) Certification from a licensed physician stating that the physical condition of the child is such that
immunization would endanger the child's life or health; or
(B) a written statement signed by a parent or guardian that the parent or guardian is an adherent of a
religious denomination whose teachings are opposed to immunizations.

K.S.A. § 72-5209

(2) a written statement signed by one parent or guardian that the child is an adherent of a religious
denomination whose religious teachings are opposed to such tests or inoculations.