AFFIDAVIT

I, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being, state
Citizen of the California Republic. 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. 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.

This written statement to exempt myself from the immunization requirement, and the Mantoux
(PPD) Tuberculin Test, 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. The acceptance
of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the
teachings of my faith.

I, {First and Last name}, am exercising my rights under the First Amendment of the US
Constitution and California Health & Safety Code #120365 to receive Religious Exemption
from Vaccination & testing.

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.
The Lord Jesus Christ and Our Creator are the only source of protection of my body and that of
my family that I can accept.

I affirm that vaccination & injections of foreign proteins conflict with my religious belief as
stated above. Therefore, I would request that you accommodate my religious beliefs and
practices by exempting me from the college vaccination and TB testing requirement.

Rest assured that I do practice a form of immunization that keeps my immune system 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___