I,_____________________________________ being of sound mind  And adult legal status

do herby make presentment that due to my religious/ spiritual beliefs / convictions as well as

claiming my United States Constitution Rights of America do hereby refuse immunization for

my child _________________________________or children


To mandate such would violate my 13th Amendment Rights of involuntary servitude.

All rights reserved without prejudice U.C.C.

1-207 and U.C.C. 1-301.6.




Notary Public, Tennessee Republic Notary






My certification expires on___________________________