In 2009, The American Academy of Pediatrics began sending out waiver templates to be given to parents who are resistant to having their children vaccinated. The documents were an attempt to harass and intimidate parents. They were steeped in the language of legal and medical terrorism. One of the documents claimed that children would get cancers without vaccines, despite the nonexistence of cancer vaccines. The forms insinuated that drastically horrible things would happen to children if parents were not compliant, and they included veiled threats that families could be broken-up at some point, due to the parent's alleged medical neglect. Once one of these forms is signed, it provides doctors, lawyers, social services personnel and the courts with what appears to be a written admission that the parents were willfully negligent in the child's care -- admitted child abusers.

Parents may not realize that they were tricked into labeling themselves as unfit parents until the document is used against them in a court of law. If they somehow manage to force you into signing one of these forms, then make certain to note on the document that it was signed under threat and coercion, and write it somewhere near your signature.

The official documents have publicly disappeared from the A.A.P. site after we covered this topic at our site (, so you may view our archived copy of one of these documents. At the top of the documents touchingly reads, "Dedicated to the health of all children".

Refusal to Vaccinate

Child’s Name:  ______________________________    Child’s ID #  _________________________

Parent’s/Guardian’s Name:  _________________________________________________________

My child’s doctor/nurse,   _______________________________________________  has advised me that my child (named above) should receive the following vaccines:

Recommended Declined
Hepatitis B vaccine
Diphtheria, tetanus, acellular pertussis (DTaP or Tdap) vaccine
Diphtheria tetanus (DT or Td) vaccine
Haemophilus influenzae type b (Hib) vaccine
Pneumococcal conjugate or polysaccharide vaccine
Inactivated poliovirus (IPV) vaccine
Measles-mumps-rubella (MMR) vaccine.
Varicella (chickenpox) vaccine
Influenza (flu) vaccine
Meningococcal conjugate or polysaccharide vaccine
Hepatitis A vaccine
Rotavirus vaccine
Human papillomavirus vaccine


I have read the Vaccine Information Statement from the Centers for Disease Control and Prevention explaining the vaccine(s) and the disease(s) it prevents.  I have had the opportunity to discuss this with my child’s doctor or nurse, who has answered all of my questions regarding the recommended vaccine(s).  I understand the following:

  • The purpose of and the need for the recommended vaccine(s)
  • The risks and benefits of the recommended vaccine(s)
  • If my child does not receive the vaccine(s) according to the medically accepted schedule, the consequences may include:

− Contracting the illness the vaccine should 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

− Requiring my child to stay out of child care or school during disease outbreaks

  • My child’s doctor or nurse, 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, I have decided at this time to decline or defer the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled “Declined.”

I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others with which my child might come into contact.

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 anytime in the future.

I acknowledge that I have read this document in its entirety and fully understand it.

Parent/Guardian Signature __________________________________   Date ______________________

Witness  ________________________________________________  Witness Date ________________

I have had the opportunity to rediscuss my decision not to vaccinate my child and still decline the recommended immunizations.

Parent’s initials ________  Date _______  Parent’s initials ________  Date_______

Parent’s initials ________  Date _______ Parent’s initials _________  Date_______


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The Claimer: The information provided herein is intended to be a truthful and corrective alternative to the advice that is provided by physicians and other medical professionals. It is intended to diagnose, treat, cure, and prevent disease.