Vaccine Exemption Template

Many are needing vaccine exemption forms as schools and businesses attempt to coerce people into getting shots to attend. Here is a religious exemption example for North Carolina. You can tailor it to any state by looking up your state statutes for religious exemptions and typing it into the form.

Update: Here’s another version that you may wish to modify or use “as is.”



If the bona fide religious beliefs of an adult or the parent, guardian, or person in loco parentis of a child are contrary to the immunization requirements contained in this Part [Chapter 130A, Article 6, Part B], the adult or the child shall be exempt from the requirements.

Upon submission of a written statement of the bona fide religious beliefs and opposition to the immunization requirements, the person may attend the college, university, school or facility without presenting a certificate of immunization. Pursuant to the aforementioned N.C.G.S. 130A-157.

 I, the undersigned, declare the Covid-19 vaccine as set forth in N.C.G.S. 130A-152 contrary to my bona fide religious beliefs as these vaccines contain aborted fetal cell lines and differ from standard vaccines by allowance of the synthetic mRNA or DNA code to enter the cells. This level of intrusion into my body’s cells is unacceptable as the body is God’s temple and defiling it could jeopardize my salvation according to my religious belief. Therefore, as permitted by law I request an exemption from the immunization requirements set forth by (Name of the institution) for admittance and participation as required by the above statute. I agree to stay home if I am ill or have a fever.

Name: _____________________________________________

Signature: ___________________________________________

Date:  ______________________________________________


Author: Lynne

I research and write about questionable cases, unfair trials, police misconduct, wrongful convictions and exonerations.

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