- NOTICES AND CONDITIONAL ACCEPTANCE -
Herein the terms “administration” and “administrators” refers to all parties providing and/or
“mandating” vaccine services and products including vaccine manufacturers, Distributors, Hospitals,
Clinics, Physicians, Nurses, Government Agents and Agencies, Healthcare Providers and all other
parties bringing vaccines to application or to market in any way.
This is agreement between the parties identified herein who on one hand, will receive vaccinations or
be affected by the consequences of vaccination including the vaccinated party/s their guardians,
representatives and all persons of common interests and, on the other hand, the administrators and
providers of the vaccine/s in all the various capacities. Those parties are identified herein as:
Individual intended for Vaccination:____________________________________
Circle one: Adult Minor
Parents' or Guardian's Names and/or Head of Household: ____________________________________
Children's names (all family members):____________________________________
__________________________________________________________________________________
Address:____________________________________
Phone:____________________________________
Other contacts if available:____________________________________
and Vaccine Administrators (below)
Authorized Officer of Vaccine Manufacturer, Name:____________________________________
Title:____________________________________
Address:____________________________________
Phone:____________________________________
Driver's license number:____________________________________
Alternate contacts and identification:____________________________________
Authorized Officer of the Organization Administering Vaccinations, Name:
____________________________________
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AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES
Title:____________________________________
Address:____________________________________
Phone:____________________________________
Driver's license number:____________________________________
Alternate contacts and identification:____________________________________
Authorized and Accountable Officer of any “mandating” government agency, Name:
____________________________________
Title:____________________________________
Address:____________________________________
Phone:____________________________________
Driver's license number:____________________________________
Alternate contacts and identification:____________________________________
Individual Administering the Vaccination to the Vaccine Recipients (Nurse, Healthcare Provider or
Other, Name:____________________________________
Title:____________________________________
Address:____________________________________
Phone:____________________________________
Driver's license number:____________________________________
Alternate contacts and identification:____________________________________
I hereby agree to and with the following stipulations, terms, declarations and positions:
1. I am aware and understand that vaccines are not a perfect or fully proven method of disease
control.
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AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES
2. I am aware and understand that vaccines are not 100% effective.
3. I am aware that vaccines have not been tested enough to show that they are 100% safe and
effective.
4. I am aware and understand that vaccines can cause death or injury and disease which seriously
and negatively affects the lives of vaccinated individuals, their families and their communities.
5. I am aware and understand that vaccines, when causing disease and injury, can cause major
costs to individuals, families and communities, which costs are solely the responsibility and
liability of the causing agents which are the administrators and providers of a harming or
ineffective vaccine.
6. I am aware and understand that vaccines cause risk which is the sole responsibility of the
administrators and providers of the vaccine.
7. I am aware and understand that no one may be forced, coerced or compelled to accept medical
treatment or foreign substances inserted into their bodies without full voluntary consent under
full disclosure and that administering a treatment, harmful or otherwise, without consent of all
affected parties is unlawful and unethical.
8. I am aware and understand that vaccinations do, on occasion, cause harm, injury and disease
including the disease they are intended to prevent.
9. I am aware and understand that there are particular dangers and hazards of combining more
than one vaccination in one or sequential administrations and some of those hazards and
dangers are not well understood and have not been fully researched, tested or proven safe or
effective.
10. I understand that individuals have different physiologies and that a vaccination which may be
harmless to one individual may be quite harmful to another individual.
11. I am aware and understand that, prior to administration of any vaccination, administrators of
vaccinations must and shall disclose to all interested parties all known and presumed risks,
hazards, harm and failures of vaccinations and all contents of the proposed vaccination/s
including all trace chemicals, adjuvants and components whether or not administrators consider
those elements to be of consequence so that the recipients of vaccinations can make fully
informed decisions with regard to accepting vaccination.
12. I am aware and understand that administration of vaccinations without full disclosure and full
voluntary consent of all interested parties and imposing risk and hazard in that way represents
criminal violation, malpractice and major liability of the administrators of the vaccination to the
vaccinated party/s should any negative consequences arise.
13. I am aware and understand that any person who attempts to enforce a “mandate” in forcing or
coercing vaccination or any other medical treatment upon any unwilling or uninformed party,
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AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES
whether or not that “mandate” is provided in law, codes or regulations, is personally fully liable
for any and all harm, loss, damage, negative consequences of the vaccination upon the
vaccinated party and all other interested parties. That liability extends to all administrators of
that “mandate”, all legislators who were involved in the creation of that “mandate” and all
companies and individuals who promoted that “mandate” through lobbying or other political
action and all parties who participate in the enforcement of the “mandate”.
14. I understand that, as an administrator or provider of any “mandated” vaccination I am assuming
all liability, obligation and responsibility for any and all negative and/or unintended
consequences of the administration of the vaccine and that I must “make whole” the recipients
of the vaccine, their guardians, families and community for any and all financial and personal
harm, damage and losses caused by the vaccine and any and all harm which may be reasonably
attributed to the vaccine. I understand that this is necessary because laws to not adequately
protect vaccine recipients and, in fact, put the public at risk of uninsured harm from vaccines.
15. I am aware and understand that I must disclose all risks of vaccination prior to administration of
the vaccine and, because vaccinations do pose risks, I must allow the recipients, guardians and
families to refuse the vaccination at their sole discretion, and that disclosure of hazards and
risks does not absolve me from any responsibility, liability or accountability for negative
consequences of the vaccinations I administer.
16. If a person suffers any disease or injury at any time after vaccination and not before vaccination
and that disease or injury cannot be affirmatively attributed to any particular cause other than
the vaccination, then I agree that it is reasonable to presume that the injury or disease was or
may have been caused by the vaccination and I will so presume and accept that theory in the
absence of compelling evidence to the contrary.
17. If the vaccine recipients, guardians, family members and interested parties of the vaccinated
party should, after the vaccination, submit claims for harm, loss, damages, injuries or disease
which they reasonably suspect to be caused fully or partially by the vaccination, then the claims
must and shall be paid and delivered by the administrators of the vaccination (above) to the
claimant/s without challenge within 30 days from submission of each claim and any challenge
to the claim/s must be made through formal written process and/or legal action. Requests for
recovery of claims paid must be supported by fact, evidence, law and moral cause. Refusal or
obstruction of service of claim shall not reduce obligations and shall be cause for escalated
claim.
18. I am aware and understand that all administrators of vaccinations are responsible for any
emotional distress caused by their vaccinations and are liable for compensation for such
emotional distress to the victim/s.
19. Administrators of vaccinations hereby agree that they will allow and facilitate recording,
videotaping, documentation and investigation of all services and processes they administer to
the vaccine recipient and that administrators of vaccinations will not refuse or obstruct that
information gathering for such reasons as “privacy” or “security”.
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20. I am aware and understand that any failure or refusal to sign this agreement causes suspicion of
intention to do harm to the vaccinated party and others and to avoid responsibility for potential
harm that may be caused by vaccination, and I am aware and understand that failure or refusal
of signature of this agreement by any administrator of vaccines is cause for rightful refusal of
vaccination by the intended vaccination recipient with law, code, regulations, contracts and
“mandates” notwithstanding.
21. Any threat of consequence for refusal of vaccination/s, such as removal from school,
quarantine, “child endangerment” etc. is coercion, is offensive, inappropriate, unlawful and
violates parental rights. There is no law and can be no valid law which would rightfully grant
authority over any individual to determine medical treatment for any other party who is in
possession of their faculties. Refusal of vaccination does not in any way imply poor judgment,
diminished capacities or social irresponsibility.
22. I am / am not (circle one) claiming that I personally have the right and authority to force
medical treatment and vaccinations upon the party (above) whom I intend for vaccination
without his/her consent. If I claim that authority, then I will provide all legal and official
reference which bestows that authority upon me specifically against the intended recipient of
the vaccination, as authorized and consented by that recipient. I understand that I must provide
evidence of authority to the satisfaction of all interested parties before the person intended for
vaccination may be vaccinated because the interested parties presume that no such authority
exists nor can exist, and, in many cases, the harm caused by vaccinations cannot be reversed.
23. I understand and agree that the person intended for vaccination is not responsible to gather
signatures on this form. The parties intending to vaccinate must acquire and share this form,
sign it and deliver it in multiple copies to any party intended for vaccination upon request. At
such time as the duly signed forms are delivered to the person intended for vaccination, those
agreement forms will be signed by the person intended for vaccination or by his/her guardian
and one copy will be returned to each administrator of the vaccination/s. If one of the requested
administrators above fails to sign and return the form, all agreements are void and vaccination is
rightfully refused.
24. Refusal to sign this form is indication of deceit, bad faith and hypocrisy on the part of a vaccine
administrator who may recommend vaccination as “safe”, but, at the same time, deny
responsibility for the hazards. If vaccinations are “safe” then refusal or hesitation to sign this
form is firm indication of misrepresentation with the assertion of “safety”.
NOTICE: If this form is refused or not signed by any vaccine administrators listed above, then refusal
of vaccine is rightful and refusal must be presumed and honored. Vaccination does pose risks, therefore
administration of vaccine without signature on this agreement by all parties called for herein or and/or
without fully informed consent by all interested parties constitutes criminal assault, malpractice,
intentional harm and violation of rights against the vaccinated parties and all other parties of common
interest by the administrators and providers of the vaccine whether any harm is caused or not by the
vaccination, therefore, without fully informed consent by all interested parties, major obligations and
liabilities arise from non-consensual vaccination whether or not the vaccination causes physical injury
or disease.
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NOTICE: Refusal to sign this form constitutes admission and warning to the prospective recipient of
vaccination that vaccination may cause harm and should be avoided in order to protect the health and
safety of those receiving treatment. This is separate and distinct from any benefit/s or “necessities” that
may be attributed to vaccinations and vaccination programs.
NOTICE: A separate agreement must be signed for each individual intended to be vaccinated.
SIGNATURES OF THE AGREEING PARTIES
Individual intended to be Vaccinated:____________________________________
Print name:____________________________________
Direct Contact information:
_________________________________________________________________________
_________________________________________________________________________________
Date:____________________________________
Parents' or Guardian's Names and/or Head of Household (if different from above):
____________________________________
Print name:____________________________________
Date:____________________________________
Authorized Officer of Vaccine Manufacturer:
____________________________________
Print name:____________________________________
Direct Contact information:
_________________________________________________________________________
_________________________________________________________________________________
Date:____________________________________
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AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES
Authorized Officer of the Organization (clinic, hospital or office) Administering Vaccinations:
____________________________________
Print name:____________________________________
Direct Contact information:
_________________________________________________________________________
_________________________________________________________________________________
Date:____________________________________
Individual Administering the Vaccination to the Vaccine Recipients (Nurse, Healthcare Provider or
Other), Name:____________________________________
Print name:____________________________________
Direct Contact information:
_________________________________________________________________________
_________________________________________________________________________________
Date:____________________________________
Authorized and Accountable Officer of any “mandating” government agency or program:
____________________________________
Print name:____________________________________
Direct Contact information:
_________________________________________________________________________
_________________________________________________________________________________
Date:____________________________________
Authorized Officer responsible for distributing the Vaccination to healthcare facilities and providers:
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AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED PARTY and NOTICES
Name:____________________________________
Print name:____________________________________
Direct Contact information:
_________________________________________________________________________
_________________________________________________________________________________
Date:____________________________________
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