AFFIDAVIT

I, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being, state Citizen of the Arkansas Republic affirm. Be it known to all
courts, governments, and other parties that:
Being a person of Strong Christian Morals, it is against my Deep, Sincerely Held, Religious Convictions to accept the injection or application of any foreign
substance into my Body. This includes, but is not limited to, any and all, X-Rays, Vaccinations, Shots, Tests for Diseases (TB tests), Oral Vaccines, Epidermal
Patches and in any other way that Radiation, Live or Killed Bacterium, Viruses, Pathogens, Germs, or any other Microorganisms, may be introduced into or
upon my body.
This written statement to exempt myself from the immunization requirement, and the Mantoux (PPD) Tuberculin Test, because I hold genuine and sincere
personal religious beliefs which are inconsistent with these medical procedures. The practice of vaccination and the injection of any foreign substance is
contrary to my conscientiously held religious beliefs and practices, and violates the free exercise of my religious principles.
The Hepatitis-A and MMR vaccines, contains the MRC-5 fetal cell line which is obtained from human babies that were electively aborted. WI-38 was
created from the tissue of an aborted fetus and is used for the rubella portion of the MMR-II vaccine. A conflict arises because my 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
Hepatitis-B vaccine protects against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps my
parental authority to condemn such activity in my child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct
contradiction to the teachings of our faith.
(We / I) {First and Last name(s)}, as the {(parent (s) / guardian(s)}of ______________________ (name of child) are exercising our rights under the First
Amendment of the US Constitution to receive Religious Exemption from Vaccination & testing.
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.
The Lord Jesus Christ and Our Creator are the only source of protection of my body and that of my family that I can accept.
I affirm that vaccination & injections of foreign proteins, and poisonous x-rays (radiation), conflict with my religious belief as stated above. Therefore, I
would request that you accommodate my religious beliefs and practices by exempting me from the employment/college vaccination and/or TB testing
requirement.
Rest assured that my family and I 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 Arkansas
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___