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 'accidentally' 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). There is NO reason whatsoever to touch the child's penis during an exam: not 'to see inside', not 'to clean' it, not 'to loosen' it, not 'to irrigate' it, not 'to see if it retracts', not 'out of curiosity', not 'to check his urethral opening', or for any other reason. (We/I) will wipe the OUTSIDE with warm water at bath time, and water or baby wipes at each diaper change. Any "cleaning" other than the afore-mentioned can cause infections and problems which stem from infections, and irreparable damage to the child's penis. Should any staff not adhere to the above information it will be seen in (our/my) eyes as criminal assault and purposeful abuse toward our son.

(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 from such needless pain and massively damaging iatrogenic interventions.

IMPORTANT:  (We/I) trust that these directions will be honored. Should any portion of this notice be disregarded, however, or should anyone at this facility attempt to coerce the signing of any consent form with respect to circumcision, (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:
                Mother Father
Date:
Signature No. 2:
Print Name:
Relationship to child:
                Mother Father
Date:


I hereby confirm on behalf of the afore-mentioned facility, that the facility has received a copy of this Notification Form, and fully understands and respects the wishes of the parent(s) in this matter.

Facility Admitting Nurse/Personnel Signature:



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