Non-Circumcision Consent Form

Copy the form below and present it to all the health care personnel who will come into contact with your baby after he is born-but do it well in advance of the birth. Most doctors, out of justifiable fears of lawsuits, will not circumcise a child if either parent objects. But you must make your objection very clear, especially if your partner favors circumcision or doesn't consider it very important one way or the other.

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NON-CIRCUMCISION NOTIFICATION FORM

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

Name of Facility:

____________________________________________________________

Address:

____________________________________________________________

(We, I, My spouse) plan(s) to use your maternal care facility for the purposes of childbirth , and hereby provide you with this notification that (our/my) male child is not to be circumcised under any circumstances.

To avoid potential 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 be marked immediately after birth, and that his nursery crib be very clearly marked:

Circumcision Forbidden

Do NOT Retract or Manipulate Foreskin

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

(We, I) wish to accord this new child a full respect for his right to physical integrity and eventual self-determination and to spare him any needless pain and potentially damaging iatro-genic interventions.

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 dual consent form at least two of the following signatures [Mother/Father/Co-Parent/Legal Guardian], (we, I) reserve the right to take appropriate legal action(s).

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

Signature ______________________________________

Print Name _____________________________________

Relationship to child (check one): __Mother __Father __Co-Parent __Legal Guardian

Date: ____________________________

Signature ______________________________________

Print Name _____________________________________

Relationship to the child (check one): __Mother __Father __Co-Parent __Legal Guardian

Date: ____________________________

Taken from: Circumcision Exposed, By. Billy Ray Boyd

Text provided by: National Organization to Halt the Abuse and Routine Mutilation of Males: P.O. Box 460795, San Francisco, CA 94146. Tel: (415-826-9351, Fax: 415-646-3700