Notice and Declaration of Parental Authority Requirement of Disclosure and Safety of Medical Treatment/s


1) Fill in the blanks of the form.

2) Sign the form.

3) Make some photocopies of the form.

4) Send the original form by certified US Postal Mail to the person who is threatening to administer medical treatment to your child without your consent. If there is more than one party threatening, then put the cc’s at the bottom of the notice and send the original to the main offender and send photocopies to any other possible offenders. It is best to use Certified US Postal Service for all copies but any mail service that provides a signed receipt of delivery probably would hold up in court.

5) Keep photocopies and all mail receipts in a well-organized file.

6) ALWAYS respond to any rebuttal, threat or objection you receive. Repeat your denial of parental consent for medical treatment of your children after each correspondence from the offending institution. Threats are not rebuttals and probably are not productive Unless the recipient can provide evidence of some form of right to determine your child’s medical treatment (e.g., juvenile court order appointing a custodian or guardian), repeat your notice with a title “NOTICE OF NON-ACCEPTANCE OF AUTHORITY TO VACCINATE”.

6) To be protected even more, if no response is received to the initial notice, send a second copy after 30 days with the title “SECOND NOTICE .” Then, after 15 more days, send a third copy titled “THIRD NOTICE” and include these words: “By your failure to respond, I/we consider you bound to the terms and requests in the original Notice that require you not to vaccinate my/our child(ren) without my/our informed consent as provided in such Notice.”

7) If anyone threatens any further medical treatment of your child, show them a copy of the correspondence and consider engaging qualified counsel to file an injunction in the appropriate local court.

8) If anyone actually administers medical treatment to your child after receiving the Notice(s), consider engaging qualified counsel to bring an action in the appropriate court for monetary damage for endangerment/harm of your child. You may need to engage a healthcare provider to serve as an expert witness to provide an expert report and/or testimony as to the harm to your child(ren). Your prior notice of no informed consent will add major power to your lawsuit. (Be sure to engage qualified counsel in support of your position and be aware of the possible bias by the court. You may have some choice as to what court/judge may have jurisdiction to hear a case like this.) 


Jerry Day and Solari Team

By Jerry Day & the Solari Team

___________________ [Parent name], parent and/or legal guardian and/or custodian of
___________________ [Child(ren)’s name(s)], hereby state that I do not give my consent to the taking of any medical action in the nature of a vaccine or similar allegedly virus-preventing physical intervention, by the administration of an injection or otherwise (hereinafter, “Vaccine”), to my above-named minor child(ren) without my express written informed consent, irrespective of my child’s expressed desires regarding administration of the Vaccine. No such “informed consent” shall be deemed to have been given in connection with a contemplated administration of a Vaccine unless the following disclosures have been provided to me at least ____ days in advance of my written consent:

Read the Form for Single-Parents

Read the Form for Two-Parents

Related Reading:

Employer & School Disclosure Forms for Covid-19 Injections

Family Financial Disclosure Form for COVID-19 Injections

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