Refusal to Vaccinate Form
Do You Know What You’re Signing When you Sign a Refusal to Vaccinate Form?
It has recently come to my attention that most, if not all of my patients, who choose not to vaccinate or choose an alternative schedule are being manipulated into signing a Refusal to Vaccinate Form that is much more dangerous than the previous medical vaccine waiver. This form is a collaboration between the individual pediatrician, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention (CDC). In short, the form asks parents to acknowledge each vaccine that they are declining or putting off per their alternate schedule with a check mark. The Pediatrician checks each vaccine that they are recommending (which is based on the current vaccine schedule). It then states that the parents have been provided with and given the opportunity to read each Vaccine Information Statement from the Centers for Disease Control and Prevention explaining the vaccine(s) and the disease(s) it prevents for each of the vaccine(s) checked as recommended and which they have declined, as indicated above. It states that they have had the opportunity to discuss the recommendation and their refusal with their child’s doctor or nurse, who has answered all of their questions about the recommended vaccine(s). A list of reasons for vaccinating, possible health consequences of non-vaccination, and possible side effects of each vaccine is said to be available at www.cdc.gov/vaccines/pubs/vis/default.htm.
It acknowledges that the parents understand the following:
* The purpose of and the need for the recommended vaccine(s).
* The risks and benefits of the recommended vaccine(s).
* That some vaccine-preventable diseases are common in other countries and that their unvaccinated child could easily get one of these diseases while traveling or from a traveler.
* If their child does not receive the vaccine(s) according to the medically accepted schedule, the consequences may include – Contracting the illness the vaccine is designed to prevent (the outcomes of these illnesses may include one or more of the following: certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, meningitis, seizures, and deafness; other severe and permanent effects from these vaccine-preventable diseases are possible as well).
– Transmitting the disease to others (including those too young to be vaccinated or those with immune problems), possibly requiring their child to stay out of child care or school and requiring someone to miss work to stay home with their child during disease outbreaks.
It goes on to say that the child’s doctor and the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention all strongly recommend that the vaccine(s) be given according to recommendations. Nevertheless, the parents have decided at this time to decline or defer the vaccine(s) recommended for their child, as indicated above, by checking the appropriate box under the column titled “Declined.” Word for word it states that “I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others with whom my child might come into contact”. I therefore agree to tell all health care professionals in all settings what vaccines my child has not received because he or she may need to be isolated or may require immediate medical evaluation and tests that might not be necessary if my child had been vaccinated. I know that I may readdress this issue with my child’s doctor or nurse at any time and that I may change my mind and accept vaccination for my child any time in the future. I acknowledge that I have read this document in its entirety and fully understand it.
The information given by the pediatrician does not give appropriate information on the risk of the vaccines. All forms of information are pro-vaccine, including the scientific articles written by doctors such as Offit, who is a co-creator of a vaccine, profiting millions of dollars from the vaccine. This information is written by authors who have significant conflicts of interest in the pharmaceutical industry and the government. Not mentioned are the VAERS website that is co-sponsored by the CDC and FDA where adverse reactions are submitted and reported https://vaers.hhs.gov/index. Another well know website that supports families hurt by vaccines along with providing up to date information is VaxTruth www.vaxtruth.org. There are many other places to look when parents are researching vaccine risks and benefits.
At the bottom of the form is the parent signature and acceptance line that again includes the statement: I have had the opportunity to rediscuss my decision not to vaccinate my child and still decline the recommended immunizations.
Refusal to Vaccinate form - Click to access the form
By signing this form you have essentially said that you believe you are putting your child’s health and life in danger while also being a threat to others. These are the exact causes that allow CPS to remove a child from their home and terminate parental rights. To refuse vaccinations is completely legal, however when this form is signed you are agreeing with everything that the letter says. That means that you are agreeing to being at the most abusive, at the least neglectful and causing danger to others.
From the conversations that I’ve had with parents in my office, who signed this form, they did not believe that they were endangering the health or life of their children or putting other children/people in danger. They did not agree with the letter at all. They signed the letter under duress for fear that they would not be allowed to leave the office (after a front office staff member stood in the doorway not allowing them to leave until the form was signed) or that the doctor would not allow them to remain a patient. They have agreed unanimously that to vaccinate or to vaccinate according to the current vaccine schedule would be abusive to their children or at the minimum neglectful knowing the lack of scientific evidence regarding the safety and effectiveness of the vaccines but knowing the high risks involved in the compounded infectious diseases along with the toxic chemicals, aborted fetal tissue and dangerous heavy metals within the vaccines. Although the vaccines have had NO scientifically acceptable double blind, controlled, placebo studies there have been study after study on the damaging effects of heavy metals and specific chemicals that are included in the vaccines. Some of the dangerous substances included in these vaccines include but are not limited to formaldehyde, Benzethonium Chloride, Glutaraldehyde, Yeast Extract/MSG, Cetyltrimethylammonium Bromide (CTMB), 2-Phenoxyethanol, Aluminum, Amino Acids and Proteins, MRC-5, DNA, MRC-5 Cellular Protein, Human Serum Albumin (4 different ingredients), Thimerosal, and Egg Protein. To know the severe dangers in each of these ingredients go to: http://vaxtruth.org/2011/08/vaccine-ingredients/.
The danger in signing this form is obvious as it gives authority for CPS to remove healthy and happy children from their homes and terminate parental rights in order to vaccinate children while they are in the custody of the state. Why they would want to do this is completely baffling to me. Why they would remove a 17 year old child from the custody of her parents for refusing chemotherapy treatment for cancer is baffling to me. The child protective program is overburdened with the current rate of children being placed into their care or removed from their homes for abuse or neglect. There are not enough foster homes or adoptive families to handle to amount of children that need to be placed now. This would add a burden to the system in enormous amounts. This would undoubtedly cause severe trauma in children and families which would constitute abuse as far as I’m concerned. It is my hope that this is not the plan for having patients sign this form, however the risk is high.
In helping parents to understand the grounds that allow CPS to remove children from parents custody I have included the Arizona Statutes directly from their website. I have highlighted in red the important portions that apply specifically to the agreed upon refusal to vaccinate form.
8-533. Petition; who may file; grounds
A. Any person or agency that has a legitimate interest in the welfare of a child, including, but not limited to, a relative, a foster parent, a physician, the department or a private licensed child welfare agency, may file a petition for the termination of the parent-child relationship alleging grounds contained in subsection B of this section.
B. Evidence sufficient to justify the termination of the parent-child relationship shall include any one of the following, and in considering any of the following grounds, the court shall also consider the best interests of the child:
2. That the parent has neglected or wilfully abused a child. This abuse includes serious physical or emotional injury or situations in which the parent knew or reasonably should have known that a person was abusing or neglecting a child.
Directly From the Arizona CPS Site ( following the link will take you to the exact page)
https://www.azdes.gov/landing.aspx?id=9670
Sometimes parents, guardians or custodians take actions that create a danger to children in the home. Other times, parents, guardians or custodians fail to act to protect their children which can or does result in their children being abused or neglected. There are several types of abuse and neglect:
Physical abuse includes non-accidental physical injuries such as broken bones, bruises, burns, cut or other injuries.
Sexual abuse occurs when there is sexual conduct or contact with children. Using children in pornography, prostitution or other types of sexual activity is also sexual abuse.
Neglect exists when parents, guardians or custodians place children at unreasonable risk of harm.
The type of abuse occurring and the level of risk to the child determine how Department of Child Safety (DCS) responds to a report. Reports of abuse and neglect are categorized as high risk, low, moderate risk and potential risk. A DCS report is defined based on ARS §8-802 as being an incoming communication to 1-888-SOS-CHILD (1-888-767-2445) containing an allegation that:
a person presently under the age of 18 is the subject of physical, sexual or emotional abuse, neglect, abandonment or exploitation which a parent, guardian or custodian has inflicted, may inflict, permitted another person to inflict or had reason to know another person may inflict AND contains sufficient information to locate the child.
The following are the major categories of abuse and neglect to which DCS responds:
Abuse
Physical Abuse
Sexual Abuse
Emotional Abuse
Neglect
Abandonment
Confinement
Non-Sexual Exploitation
The following persons are required by law to report:
Any physician, physician’s assistant, optometrist, dentist, osteopath, chiropractor, podiatrist, behavioral health professional, nurse, psychologist, counselor or social worker who develops the reasonable belief in the course of treating a patient.
Any peace officer, member of the clergy, priest or Christian Science practitioner.
The parent, stepparent or guardian of the minor.
School personnel or domestic violence victim advocates who develop the reasonable belief in the course of their employment.
Any other person who has responsibility for the care or treatment of the minor.
I understand that this is a very emotional and difficult issue and am not attempting to change the mind of parents regarding vaccine choice. My one and only purpose for writing this letter is to inform patients of the danger in signing this form and stating the reason that the parents I’ve personally discussed this issue with, disagree with the form and have still signed out of fear. Should a parent sign this form and completely agree with it, there is nothing that needs to be done. If a parent has signed this form and does not agree with it’s contents, it is imperative that you immediately rescind your signature (agreement) and have the physicians office who has the signed form sign your correctly written form, understanding your disagreement with this form and your lack of understanding when it was initially signed. This form can be created by you and put in your child’s file but you must also get a copy for yourself signed by your doctor to prove it’s existence, should there ever be a need to prove that you did not agree to endangering your child’s health or life or to putting other children/people in harm.
Yours in Health and Freedom
Dr. Ashley Waggoner-Jones, Chiropractic Physician
www.ashley-chiropractic.com
www.facebook.com/ashleychiropracticatkeystone