Principal [Yours]

School Address
School Address

Date

Re: Student: [child’s name] (d.o.b. x/xx/xx)

Letter Stating Beliefs Opposed to Immunization (Cal. Health & Saf. Code § 120335(g)(1)

Dear [Principal of your child’s school],

We are writing this letter in compliance with California Health & Safety Code section 120335
(g)(1), which requires parents seeking to exempt their child from the requirements of the new
mandatory vaccination law (California Senate Bill 277) to submit, “a letter or affidavit with his or her
school (any public or private school) stating their beliefs opposed to immunization” prior to January 1,
2016.

This letter is to inform you and/or the administrator of any future school my son, [child’s name],
may attend that the administration of each of the ten enumerated vaccinations made mandatory by the
new law (measles, mumps, rubella, polio, Hib, Hepatitis B, diphtheria, pertussis, tetanus, and chicken
pox) conflicts with our personal health care philosophy and our religious beliefs and practices.
Specifically, we have strong religious convictions which find the development of modern vaccines using
aborted fetal cell lines morally reprehensible—a practice we cannot condone, support, or in any
participate in.

For these reasons, we have executed the Personal Belief Exemption (PBE) affidavit form put out
by the California Department of Public Health, which is already on file with [name of your school]. We
request that you add this letter to [your child’s name] file immediately as well. According to the explicit
provisions of Health & Safety Code section 120335 (g)(1), the submission of this letter prior to January 1,
2016 along with the PBE affidavit already on file will ensure that [your child’s name] is “allowed
enrollment to any private or public elementary or secondary school, [or] child day care center […] within
the state until [he] enrolls in the next grade span.” As a [x] grade student, [your child’s name] next
grade span begins in [x] grade.

Furthermore, because the new vaccine law also allows physicians and nurses to come onto
school campuses for the purpose of administering vaccinations, we want to be clear that AT NO TIME
DOES ANY PHYSICIAN OR NURSE HAVE OUR PERMISSION TO ADMINISTER ANY VACCINATIONS TO
OUR MINOR SON [your child’s name] FOR ANY PURPOSE. Should the bodily integrity of [your child’s
name] be violated in this manner, we will not hesitate to pursue any and all legal remedies available to
us under California law.
 Should you have any questions regarding the contents of this letter, please do not hesitate to
contact us.

Sincerely,

Your Name
Your Spouse’s Name
Your Address
Your Phone Number