Form for Students Attending a College or University Requiring Covid Injections

All over America, students are facing a very tough decision right now. Although some wish to accept a Covid-19 injection, many do not. The problem is that a growing number of colleges and universities are trying to deny students’ right to choose and their right to bodily integrity by requiring the vaccines as a condition of academic enrollment. In the United States and other jurisdictions, that is a violation of the law. It is also a violation of fundamental human and religious rights. As the Association of American Physicians and Surgeons recently wrote, “Students and their families may justifiably believe these policies discriminate against individuals who aren’t candidates for this vaccine, have pre-existing conditions, previous COVID-19 disease, cite religious objections, or are otherwise exercising their freewill choosing not to participate in this optional vaccine experiment.”1

In the U.S., the provisions of the 2005 Public Readiness and Emergency Preparedness (PREP) Act and a February 2020 declaration by the Secretary of the Department of Health and Human Services (HHS) mean that pharmaceutical companies cannot be held liable for injuries or deaths caused by the Covid-19 injections.2

However, other institutions and individuals can be held liable. This form is designed as a tool that students and their families can use to provide this critical information to colleges and universities, and to insist on a signature from the school’s representative that holds the college or university liable if the student should decide to accept the required experimental Covid-19 injection.

We are already seeing that health care providers are refusing service to individuals injured by the experimental Covid-19 injections, and health and life insurance companies are declining coverage for vaccine-related injuries and deaths on the grounds that the injections are investigational vaccines allowed under Food and Drug Administration (FDA) emergency use authorization (EUA) but not otherwise approved or licensed.3

This denial of care and coverage poses a serious threat to the physical and financial well-being of students presented with a requirement to get a Covid injection—perhaps even more so than the possibility of losing their place at school for not being vaccinated.

Reviewing this form with colleges and universities may open educational institutions’ eyes to the regulations in place and the liability they may face (that they may otherwise not be aware of). Students should consider reviewing the form with their school as well as sharing it with other students. This could result in a positive impact for students and could be a game-changer. Alternatively, if the college or university representative refuses to sign the form, that may be an indicator of their concern about potential liability and should prompt an immediate discussion about how the student can attend school without being injected.

If you find yourself in a predicament with a school that refuses to hear you out, does not provide you with required information, or threatens you with expulsion, here are a few potential resources for contacting attorneys. America’s Frontline Doctors provides an intake form on their site that you can fill out and submit, and they will search for an attorney in your area who is taking on this type of case.4

There is a small fee for the search, and of course, attorneys have their own fees. The legal team of the Informed Consent Action Network (ICAN) is offering to assist students who are being required by a college or university to receive the Covid-19 injection.5

If you find yourself needing a vaccine injury case attorney, you might also try looking through this state list.6

This form was written by Corey Lynn of Corey’s Digs for The Solari Report.

Click here to download the student form in PDF format. Please note that two other forms are available as downloadable PDFs: the Family Financial Disclosure Form,7 and Form for Employees Whose Employers Are Requiring Covid-19 Injections.8

NOTE TO STUDENT: Be sure to document the date and time you submit this form to your school; also document the date and time and their response if they refuse to sign it.



  1. Association of American Physicians and Surgeons. Open letter from physicians to universities: allow students back without COVID vaccine mandate. AAPS, Apr. 24, 2021.
  2. Congressional Research Service. The PREP Act and COVID-19: Limiting Liability for Medical Countermeasures. Updated Mar. 19, 2021.
  3. Del Bigtree interviews 3 medical professionals incapacitated by Covid injections. The Highwire, Apr. 29, 2021.
  4. America’s Frontline Doctors. Vaccines & the law.
  5. Catharine Layton. Forced to get the COVID vaccine? ICAN may be able to help. The Defender, Jan. 29, 2021.
  7. The Solari Report. Family Financial Disclosure Form for Covid-19 injections. Mar. 1, 2021.
  8. The Solari Report. Form for Employees Whose Employers Are Requiring Covid-19 Injections. May 3, 2021.
  9. Centers for Disease Control and Prevention. COVID-19 Vaccine Emergency Use Authorization (EUA) Fact Sheets for Recipients and Caregivers.
  10. UK Medical Freedom Alliance. COVID-19 Vaccine Info.
  11. Vaccine Adverse Event Reporting System.
  12. CDC WONDER. About the Vaccine Adverse Event Reporting System (VAERS).
  13. National Vaccine Information Center. Search the U.S. Government’s VAERS Data.
  14. U.S. Department of Health and Human Services. Emergency Use Authorization of Medical Products and Related Authorities: Guidance for Industry and Other Stakeholders. January 2017.
  15. 21 U.S. Code § 360bbb–3 – Authorization for medical products for use in emergencies.
  16. Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003).
  18. Federal Trade Commission. Advertising FAQ’s: A Guide for Small Business.
  19. Federal Trade Commission. Truth in Advertising.
  20. U.S. Department of Health and Human Services. Office for Civil Rights. Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information.;jsessionid=618E88DD94EE65D46D5785CB2A643553.

Download the Student Form
Download the Employee Form
Download the Family Financial Disclosure Form