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___________________________