AFFIDAVIT

I, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being(s), state Citizen(s) of
the Wyoming 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 of any foreign substance into my Body or the Body of my 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 child from any immunizations, TB testing, and other shots/injections,
because I 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 conscientiously held religious beliefs and practices, and violates the free exercise of my
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
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 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/am exercising our rights under the First Amendment
of the US Constitution and California Health & Safety Code #120365 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.

Our Creator Yahweh is the only source of protection of my body and that of my family that I can accept.

I affirm that vaccination & injections of any foreign substances and proteins conflict with my religious
beliefs as stated above. Therefore, I would request that you accommodate my religious beliefs and
practices by exempting my child from any vaccination or injections of any kind.
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 California

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___

California Health & Safety Code

IMMUNIZATION NOT REQUIRED WHEN CONTARY TO PERSONAL BELIEFS

Immunization of a person shall not be required for admission to a school or other institution listed in Section 120335 if
the parent or guardian or adult who has assumed responsibility for his or her care and custody in case of a minor, or the
person seeking admission if an emancipated minor, files with the governing authority a letter or affidavit stating that
immunization is contrary to his or her beliefs. However, whenever there is good cause to believe that the person has been
exposed to one of the communicable diseases listed in subdivision (a) of Section 120335, that person may be temporarily
excluded from the school or institution until the local heath officer is satisfied that the person is no longer at risk of
developing the disease.
(Added by Stat. 1995, Ch. 415, Sec 7)