Vaccine Education Video Attestation Form

Overview

Before completing this form, please carefully review the following:

  • This form applies to parent/legal guardian seeking an exemption for your child(ren) from a  required program of immunization on the basis of conscience and religious belief (non medical) under the Immunization of School Pupils Act, R.S.O. 1990, c. I. 1.
  • If your child requires a medical exemption from a required program of immunization, please have your health care provider complete the form titled, Statement of Medical Exemption – Immunization of School Pupils Act
  • This form applies to children who live or attend school in York Region. If your child does not live or attend school in York Region, please use the public health unit locator tool to find your correct public health unit.

Notice of Collection

Personal information is being collected in this form pursuant to the authority of section 4(4) of R.R.O. 1990, Reg. 645 under the Immunization of School Pupils Act, R.S.O. 1990, c. I. 1 for the purpose of verifying completion of an immunization education session and providing a completion certificate. If you have any questions regarding the collection, use and disclosure of this information, please contact our Immunization Services staff at 1-877-464-9675 ext. 73456.

If you want to speak to a nurse regarding the education session or require more information on immunizations, please call 1-877-464-9675, ext. 73452.

For information on the immunization exemptions forms, contact York Region Public Health at 1-877-464-9675, ext. 73456.

Attestation

I have viewed the entire “Vaccine Education Video”. I understand that completion of an immunization education session provided by my local public health unit, York Region Public Health, is required in order for my “Statement of Conscience and Religious Belief Immunization of School Pupils Act" form to be processed. I certify that the information I have disclosed in this form is true, complete, and accurate.

Receiving Your Certificate

How would you like to receive your Vaccine Education Certificate?

The certificate will be sent by encrypted email from [email protected] within
5 business days after this form has been received.
The certificate will be sent by regular mail within 5 business days after this form has been received.