| CONTACT INFORMATION |
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| VIEWS ON VACCINES: |
| Do you object to all vaccines or only specific ones? Please check all that apply: |
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| Why do you object to one or more vaccines? Please check all that apply: |
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| REJECTED VACCINE EXEMPTIONS: |
| Have you been rejected for a medical exemption to vaccination? |
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| Have you been rejected for a religious exemption to vaccination? |
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| Please select the official(s) that rejected the vaccine exemption (please check all that apply): |
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Please describe what happened in your own words in the box below. If you want what you describe in the box below to be publicly posted on the "Cry for Vaccine Freedom Wall" on this website, please check "YES" (personal identifying information will NOT be posted, only the narrative you write below). If you do NOT want what you describe in the box below to be posted on this website, please check NO.
YOUR NARRATIVE |
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| FAMILY AND PERSONAL HISTORY |
| Do YOU, or your CHILD or your FAMILY have a history of (please check all that apply): |
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| Would you like to speak publicly about being harassed about your beliefs about vaccination? |
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| Thank you for taking the time to fill out the above form. |
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Disclaimer and Legal Information
The information contained on this website is for educational purposes. While we strive to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the website or the information, products, services, or graphics contained on the website for any purpose. Any reliance you place on such information is therefore strictly at your own risk.
In no event will the National Vaccine Information Center, or any participant, contributor, endorser, or other associate of any kind thereof, be liable for any loss or damage, including, without limitation, indirect or consequential loss or damage, or any loss or damage whatsoever from any activities arising out of or in connection with the use of this website.
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