Freedom of Religion and the 31+ Question Test
NY Public Health Law � 2164 and �
2165 mandates the vaccination of children before they will be admitted to school, yet section 9 declares that the
"... shall not apply to children whose parent, parents, or guardian hold genuine and sincere religious beliefs which are contrary to the practices herein required, and no certificate shall be required as a prerequisite to such children being admitted or received into school or attending school."
Despite the clarity of this spare text, parents seeking the
religious exemption, find local school boards throughout the state
subjecting them to questionnaires, face-to-face interrogations
and demands for family health and
dental records, all under the rubric of validating the
"sincerity" of their beliefs.
William B. Heebink, Superintendent of the Clarkstown Central
School District, requires claimants to accede to all of the
Given that section 9 requires only that the parent "hold genuine and sincere religious beliefs," the
31 part questionnaire
presented to parents by Mr. Heebink, as a prelude to his
required in-person meeting, makes one wonder what is taught in
the Clarkstown schools regarding the First Amendment and the
CLARKSTOWN CENTRAL SCHOOL DISTRICT
SWORN IMMUNIZATION EXEMPTION QUESTIONNAIRE
[name withheld] AND [name withheld], BEING THE NATURAL PARENTS OR GUARDIANS OF [name withheld] (D.O.B. _/_/_), HEREBY SWEAR THAT THEIR ANSWERS TO THE FOLLOWING QUESTIONS ARE TRUE TO THE BEST OF THEIR KNOWLEDGE, AND THAT THEY SUBMIT THESE ANSWERS IN SUPPORT OF THEIR APPLICATION TO THE
CLARKSTOWN CENTRAL SCHOOL DISTRICT FOR AN EXEMPTION FROM IMMUNIZATION REQUIREMENTS AS CONTAINED WITHIN THE EDUCATION AND PUBLIC HEALTH LAWS IN CONJUNCTION WITH THE APPLICATION TO ADMIT [name
withheld] INTO KINDERGARTEN AT THE [name withheld] ELEMENTARY SCHOOL (please answer for both parents/guardians where appropriate):
1. Are there any other children within your household, whether by adoption or natural childbirth? If so, please state their names, dates of birth (D.O.B.'s) and places of birth, as well as [name withheld]'s place of birth (please attach copies of all birth certificates).
2. Who has supplied medical care for your children, at and since birth? Has any child ever been vaccinated or immunized? Taken medication whether prescribed or over the counter? Been hospitalized? Been subject to medical or dental procedures? If so, provide the names and locations of all doctors, dentists, names of all medications, types of vaccinations or immunizations, describe all procedures, supply the name and location of all hospitals, and describe the circumstances.
3A. Has either parent or guardian in the past five years taken any medications, whether prescribed or over the counter? If so, what medication and for what purpose? If prescribed, by whom? Are you still taking those medications?
B. Has either parent or guardian in the past five years been hospitalized, or subject to a medical or dental procedure? If so, where was the hospitalization and for what purpose? If subject to a procedure, what was the procedure?
C. With respect to A) and B), supply the names and addresses of all doctors or dentists who were involved.
4. At what point in time and under what circumstances did each of you adopt the beliefs which you claim preclude allowing your children to be immunized?
5. Please describe all churches and/or religious organizations each of you are presently a member of (please give name of same, address, telephone number, and the names of the religious leaders of same).
6. As each of you was growing up, were you raised as a member of any church or religious organization? If so, please describe.
7. Were you married in a religious ceremony? If so, please describe, including date.
8. If the answer to question number "5" or "6' is yes, did either of you then and do you now consider yourself to be a member of or adherent of, the teachings of that religion or religious group?
9. Is either of you a member of, or adherent of, any other religious group, or religious practices or teachings? If so, please describe the group, practices and teachings.
10. Please each describe your profession and/or occupation and post-high school education.
11. Please name and give the address, telephone number, and website and e-mail address (if known) of any organization to which either of you belongs which, directly or indirectly, is medically related, or has a position with respect to immunizations.
12. Irrespective your religious views, does either of you have an opinion about the medical efficacy of immunizations in general, or certain immunizations in particular? If so, what is that opinion? Please describe it in detail.
13. Please describe your respective medical beliefs, in general.
14. Do and have your children receive regular medical check-ups or examinations by a licensed pediatrician or any licensed medical doctor? If so, by whom and when?
15. Are you also claiming that your child has a medical condition warranting a medical exemption? If so, please describe the medical condition necessitating an exemption and attach medical reports describing said condition.
16. Does either of you regularly attend religious services at a Church, Synagogue, Mosque or the meetings of any religious group, or any group which professes to have religious beliefs? If so, please describe the religion or group and its beliefs.
17. Was your child or any of your children, baptized, christened or circumcised? If so,
which child, when and which event?
18. Was either of you baptized, christened or circumcised? under the auspices of what religious group?
19. If so, when, where, and was either of you formally recognized as adult members of any religious or religious group, such as by confirmation or bar or bas mitzvah? If so, which group, and please describe in detail.
20. Has [name withheld], and your other children, if any, been raised as members of any religion or religious group? If so, which group, and please describe in detail.
21. Please describe each of your religious beliefs in detail, including those beliefs which you claim preclude immunization or vaccinations.
22. Does either of your religious beliefs preclude the use or ingestion of any other substances, including medicines or supplements of any kind, or the use of medical or dental procedures, even if physician or dentist recommended? If so, describe in detail.
23. Is either of you presently a member of any religion or religious organization, congregation, or religious sect or a practitioner of any religion or religious organization, which holds amongst its beliefs the belief that vaccination or immunization is prohibited? If so, please name the religion or religious organization, state its address (local and national) and explain the associated beliefs in detail, and state how long you have been a member or practitioner of same.
24. Does the group described in answer to #22 have any books, pamphlets, texts, devotional materials or any other written materials which describe its principles, tenets, or precepts or which are used in the conduct of religious services, or personal prayer, or which explain the beliefs of the Congregation? If so, please describe and supply copies of same.
25. Do you and other congragants or practitioners of the religion described in # 22 regularly meet at any place for religious services? If so, when and where and under what circumstances?
26. Do you know of any common bond or similar aspect in the background of the congregants or practitioners of that religion or congregation other than being adherents of the religion?
27.Did you obtain prenatal medical care for [name withheld] (or her brothers and sisters, if any)? If so, by whom was such care given? Please give the name and locations of any facility or hospital where such medical care was given, medical practitioners involved and dates, and the nature of the care.
28. In order to assist the Superintendent in making his decision, kindly supplement the above by describing in an attached writing in your own words in as much detail as possible, or as you may wish, answers to the following questions:
a) Please describe your religious beliefs?
b) When did you first ascribe to those beliefs?
c) How many of those beliefs changed, if at. all,. and when did those changes occur and under what circumstances?
29 What were the circumstances of the creation of the letter submitted dated
[date removed], over the name of an attorney, [name withheld]? Why was this letter created and how was it to be used?
30. There are quotes in the [date removed] letter attributed to you. Did you author any of the quoted material or personally select of your own knowledge such for inclusion in the letter?
31. Also with respect to the above letter, did you supply the biblical quotes to your attorney? If so, were you and are you knowledgeable about scripture and verse?
If you wish to attach any expanded answer, statement or documents please list them and attach.
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