NO Circ Pledge with optional doctor acknowledgment

I wrote this for someone this morning. Please feel free to copy and use it. I am freely giving permission for anyone to use my words and share it with anyone who is interested in signing a pledge for their son. You may make modificiations according to your particular situation. With a few changes this could be also written for a daughter. If anyone wants the original text file emailed to them, please drop me a note at and I will send one right out to you. I made two versions, one with a space for doctor's signature indicating they have received a copy to keep on file in the doctor's office.


I, _______________________________________

and _____________________________________,

parent(s) of baby named _______________________________________

born on this date________________________________________

do swear on this date __________________________________________, 20______ that I/we will not consent to having my child undergo the procedure known as circumcision, from this day forward.

Circumcision is the removal of healthy tissue on the tip of the penis known as a foreskin. A foreskin, or prepuce, serves many important functions that I/we want my child to enjoy the benefits of.

In addition, I/we also pledge to properly care for my intact son. I/we will go by the rule of “Intact, don't retract.” I/we will clean only what is seen. I/we will not retract my child's foreskin and I/we will not allow or consent to any medical professional, babysitter or caregiver or any other person to do so as well.

I/we claim for my child his natural birthright to a whole, intact body.


Parent Signature

Parent Signature

Physician's signature indicating this document is on file for this child:

Physician Signature Date


Anonymous said...

Very nice, i suggest admin can set up a forum, so that we can talk and communicate.

Anonymous said...

Which came first? chicken or the egg