Form for Students Attending Colleges or Universities Requiring Covid-19 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.2However, 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.3This 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.4There 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.5If 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.

NOTE TO COLLEGE OR UNIVERSITY: As a student at your institution, I am requesting that you review this document, provide the requisite information, and sign the form, in regards to your requirement that students get a Covid-19 emergency use authorization (EUA) experimental vaccine.

1) If I agree to receive an EUA Covid-19 injection, does my student health insurance plan [if applicable] provide complete coverage should I experience an adverse event, or even death?




2) As a student at your institution, will you provide any other medical or financial support to me or my family if I have an adverse event to an EUA Covid-19 injection and am unable to attend school for days, weeks, or months, or if I am disabled for life?




3) The Food and Drug Administration (FDA) requires that EUA vaccine recipients be provided with certain vaccine-specific information to help them make an informed decision about vaccination.9The EUA fact sheets that must be provided are specific to each authorized Covid-19 injection and are developed by the manufacturers of the injections (Pfizer/BioNTech, Moderna, Oxford/AstraZeneca, and the Johnson & Johnson subsidiary Janssen). The fact sheets must provide the most current and up-to-date information on the injections, and vaccine recipients must also receive information about adverse events. Have you read, understood, and provided me (and all other students) with these fact sheets and with current information on adverse events so that I/we can make an educated decision?



4) Have you reviewed the available databases of material adverse events reported to date for people who have received experimental Covid-19 injections?10,11,12,13 Potential and reported adverse events include death, anaphylaxis, neurological disorders, autoimmune disorders, other long-term chronic diseases, blindness and deafness, infertility, fetal damage, miscarriage, and stillbirth.



5) The FDA’s guidance14on emergency use authorization of medical products requires the FDA to “ensure that recipients are informed to the extent practicable given the applicable circumstances…[t]hat they have the option to accept or refuse the EUA product….” Are you aware of this statement? Have you informed all students that they have the option to refuse?



6) With respect to the emergency use of an unapproved product, the Federal Food, Drug and Cosmetic Act, Title 21 U.S.C. 360bbb-3(e)(1)(A)(ii)(I-III)15reiterates that individuals be informed of “the option to accept or refuse administration of the product, [and] of the consequences, if any, of refusing administration of the product, and of the alternatives to the product that are available and of their benefits and risks.” If experimental EUA Covid-19 vaccines are ever approved by the FDA, state legislation would be required to allow companies to mandate the Covid-19 injections. Are you aware of these facts?



7) EUA products are unapproved, unlicensed, and experimental. Under the Nuremberg Code—the foundation of ethical medicine—no one may be coerced to participate in a medical experiment. The individual’s consent is absolutely essential. No court has ever upheld a mandate for an EUA vaccine. In Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003),16 a federal court held that the U.S. military could not mandate EUA vaccines for soldiers: “…[T]he United States cannot demand that members of the armed forces also serve as guinea pigs for experimental drugs” (Id. at 135). Are you aware of this?


8) The United States Code of Federal Regulations17and the FDA require the informed consent of human subjects for medical research. The EUA Covid-19 injections are unapproved, unlicensed, investigational vaccines that are still in their experimental stage. It is unlawful to conduct medical research on a human being, even in the event of an emergency, unless steps are taken to secure the informed consent of all participants. Are you aware of this?


9) According to Federal Trade Commission (FTC) Guidelines18and the FTC’s “Truth In Advertising,”19 promotional material—and especially material involving health-related products—cannot mislead consumers, omit important information, or express claims. All of this falls under the rubric of “deceptive advertising” (whereby a company is providing or endorsing a product), whether presented in the form of an ad, on a website, through email, on a poster, or in the mail. For example, statements such as “all students are required to get the Covid-19 vaccine to make the campus safe” or “it’s safe and effective” leave out critical information. Critical information includes the facts that Covid-19 injections are unapproved EUA vaccines that “may” or “may not” prevent Covid, won’t necessarily make campuses safer, and could in fact cause harm. Not providing links or attachments of the manufacturers’ fact sheets and current information on adverse events is omitting safety information. Are you aware of this?


10) Since the Covid lockdowns began over one year ago, there have been over 178 reported breaches of unsecured protected health information (PHI), incidents investigated by the Office for Civil Rights (OCR). These breaches exposed millions of people’s personal health information. Although many of these incidents were attributed to hacking, some of the breaches to PHI fell directly under the 1996 Health Insurance Portability and Accountability Act (HIPAA), such as sharing a patient’s or person’s information with an unauthorized individual or incorrectly handling PHI.20 Can you please explain your obligations to me, under HIPAA law, and how you are going to protect my personal information – both with respect to your requirement that I receive this injection?





11) Whereas pharmaceutical companies that manufacture EUA vaccines have been protected from liability related to injuries or deaths caused by experimental agents since the PREP Act2 was enacted in 2005, companies, schools, and all other institutions or individuals who mandate experimental vaccines on any human being are not protected from liability. Are you aware that you do not enjoy such liability protection?


12) Are you aware that students or families could file a civil suit against you should the student suffer an adverse event, death, or expulsion from school for refusing an EUA Covid-19 injection?



As the legally authorized officer of the college or university, I have read all of the above information, have provided my students with all of the information that the FDA requires be provided to recipients of the Covid-19 injections, and do hereby agree to assume 100% financial responsibility for covering any and all expenses from adverse events, including death, through insurance coverage or directly. In addition, I affirm that the student shall not be denied access to school should they decline to receive a Covid-19 injection.


  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.
  22. htps://

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Corey Lynn is an investigative journalist. Support her work by becoming a Patron or making a donation. Follow her at, on Gab, GabTV, and YouTube.


  • Lisa

    Absolutely excellent Corey. Thank you for gathering details (devils in the details) & legal references.
    I called Primary Health here in Garden City, Idaho. Nurse was totally unaware shots are experimental even though she administers them to patients. She just, “hands out the paperwork”. I asked if paperwork said experimental & she said she did not know.
    As a semi-retired RN I am shocked & see it as unethical that a provider administering shots would not have educated their employees or that nurse would have not research this unapproved these “concoctions”-(sorry but it was what dame to mind) described as a vaccine.
    Thank you again Corey for your diligence. Love & appreciate the thoroughness you put into your digs!! May God Bless you & yours.

  • Susan L Hough

    Thank you Corey!!! I have been looking for info for both my college student and high school student on this and appreciate all you do to keep us informed and armed with the truth. This is a hard one on parents. God Bless you!

  • Robyn

    It goes against the Florida compilation of school discipline laws and regulations part V 1003.573
    Its called PROHIBITED RESTRAINT period done over

  • David Robertson

    Oddly enough, the word concoction also came to my mind recently when describing the contents of this Jab. It is a witches’ brew of ingredients apparently designed to enslave us forever. Thanks, but no thanks.

  • Cecille Chan

    I think we are at a time when the Cabal puppets do not care what information you show them or what papers you have them sign as long as their primary aim of genocide is carried out. The Constitution, the precedents from the Nuremberg trials, and the God-given natural human rights be damned. This Deep State/NWO totalitarian society is barreling into our reality at “warp-speed” greatly aided by the complacency of the populace while waiting for “the plan” to be carried out. We were actually horses being led to slaughter, not water/freedom. Here are the people you have been looking up to, to preserve your freedom. They all belong to the same “club” George Carlin often spoke about. “And you are not in it”. It is long, but you will see your “hero” towards the end of the video. I’ve done my share. Over three decades of trying to wake up people to the reality of the NWO. Most of the time, all I got in response were scoffs. I am worn and weary. Even my last name feels like a curse right now. The useful idiots are zeroing in on that.

  • Hanna

    Thank you so much. It is exhausting to be in the minority regarding this subject. I’m stunned there are so many willing to put their life in jeopardy and are sucked into this advertising campaign. We have been very upset as parents of teenagers, one who has plans to attend a university that requires this shot.
    Cecille, I think of George Carlin often now, I can picture him saying “See!! I told you!!”.


  • Frank Furter


    It’s nice to see an Asian-American who knows what is really going on! Thank you for your comments. I too, get very frustrated at seeing so many people walking around thinking “they (the government) are here to take care of us.” Sometimes I feel like I’m walking amongst a sea of zombies. Is it the fluoride in the water? How did people get so dumb? One contributing factor I think is that most people have no solid knowledge of good and evil and think that “everyone has good intentions.” Keep up your good work, and please don’t lose hope! We (those who know the truth) need to stay strong and stick together!

  • Mary

    Thank you Corey Digs. We remain strong if we all stay strong and united. I believe we are too many if we stay strong and stay firm. Freedom is our call!

  • alice

    What a thorough and excellent piece of work. Thank you.

    I don’t think most Brits realise that the vaccinations aren’t approved. We are a nation of guinea (?) pigs. I don’t know anyone else who has declined to be vaccinated and people are puzzled that I won’t have it. The Lord designed me with an immune system so why would I need their witchcraft? Not listening to main stream media makes all the difference – this country was pounded with rhetoric, an endless stream of lies and … it seems to have worked. Next step, passports – bring ’em on.

  • Kim

    Is there a form for nursing home or assisted living residents if they are told they must get the vaccine??Thank you

  • Leonie

    Here’s a very good video of 5 very important specialist doctors discussing the “vaccine” or bioweapon as they call it. Please pass it on to everyone- Farcebook will delete it so I went through Messenger but if you’re on another platform go for it. Copy and paste below.

  • Rochelle eisele

    Thank you for this information. I’m with all of you. I have three teenagers and I’ve been up many nights thinking , what will I do when they are told you are forced to get this vaccine or no college , no sports . We all need to fight this. Where is our rights? This was the land of the free – how can they force us to put something in our kids bodies ? This has to be stopped.

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