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 purposes of childbirth, and hereby provide you with this notification that (our/my) male child is NOT TO BE CIRCUMCISED under any circumstance.
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 prepuce (foreskin).
(We, I) wish to accord this new child a full respect for his rights to physical integrity and eventual self-determination and to spare him any needless pain and potentially damaging iatrogenic 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 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:_____________________________ |
Form courtesy: 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]