NOTE:  None of this information should not be construed as legal council. The information is merely provided as a format so people may have some idea of how others have proceeded in similar situations.  State laws vary from state to state.  This format was used in Missouri.

SUGGESTIONS: 

First - prepare the certificate.  Find a notary (maybe at your bank).  A raised seal might be preferable.  Several copies (probably at least 4, with original seal) will probably be helpful.  Remember, one is to be filed with your County Health Department.  The other is to be filed with your place of employment.  In either case, you will want a receipt that your Certificate has been received.

The Certificate of Attest needs to be filed with your County Health Department.   Considering my personal  experience filing papers, you may find it very helpful to find out the department head's name or responsible  person at the Health Department to whom you should  address your paper which needs to be recorded. (In other words, who is the Recorder at the Department of Health)?

Send your Certificate of Attest by Certified Mail-Restricted Delivery Only.  (This means only the person you specify can sign for it.  This will provide a responsible party who has signed for this, rather than just having it accepted in the general mail with no one individual responsible. You may need this information later.)

Scroll down to view the certificate.  With a little luck this page will print as two pages: the first with these instructions, the second with the certificate.

CERTIFICATE OF ATTEST

___________________
Today's Date


Per provision of Missouri Statute on religious exemptions, I, ______________________, hereby request to be exempted from compulsory vaccination, inoculation, medicament, or other medical measures as such treatment conflicts with my religious beliefs.


_____________________________   ________________________ 
Name                                                           Date


_______________________________________________________
Address

_______________________________________________________
City, State, Zip Code



_____________________________   _________________________ 
Witness                                                       Date


_____________________________   _________________________ 
Witness                                                       Date