Circumcision-refusal form

Non-Circumcision Notification Form

ATTENTION:

Maternal-Infant Care Staff, Physicians, Nurses and other personnel at:

Facility Name:_________________________________________________________________

Address:_____________________________________________________________________

We/I/My spouse plan/s to use your maternal care facility for the birth of our baby/babies, and hereby notify you that our/my/her child/ren if male is/are NOT TO BE CIRCUMCISED under any circumstances.

We/I further direct that no attempt be made by anyone at this facility to stretch, retract or otherwise manipulate our son's prepuce (foreskin).

To avoid any possible error whereby this child could be circumcised, we/I hereby direct that the mother’s chart be immediately marked upon admission, that the child’s chart if male be marked immediately after birth, and that his nursery crib be very clearly marked:

THIS BABY MUST NOT BE CIRCUMCISED

OR HAVE HIS FORESKIN RETRACTED

IMPORTANT: We/I trust that these directions will be honored. Should any portion of this notice be disregarded, however, or should this child be circumcised based on any consent form not bearing all of the signatures below, we/I reserve the right to take appropriate legal action/s.

This document becomes legally binding with at least one signature below.

Signature No. 1:



_________________________________



Print Name:



_________________________________



Relationship to child: (circle one)



Mother Father Co-Parent Legal Guardian



Date:_____________________________ Signature No. 2:



_________________________________



Print Name:



_________________________________



Relationship to child: (circle one)



Mother Father Co-Parent Legal Guardian



Date:_____________________________ Seen by

(name):____________________________(Signature:)________________________

representing the facility

Position:___________________________ on (date:)______________________

Photocopy the signed document and keep a copy.





Form based on that of the National Organization to Halt the Abuse and Routine Mutilation of Males

PO Box 460795 - San Francisco, CA 94146 Tel 415.826.9351 - Fax 305-768-5967 [Rev.06/97]

You can download this form in Word (*.doc) format or in .pdf format (which requires Adobe Acrobat Reader ) with the template for a sheet of these stickers:





Related pages:

Back to the Intactivism index page.