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Submit a Statement of Conscience or Religious Belief Affidavit

Important

Before completing this form, please carefully review the following:

I have a Statement of Conscience or Religious Belief Affidavit signed by a Commissioner of Oaths, such as a lawyer, Member of Parliament, or Town Clerk.
I am the parent/legal guardian for the child and the affidavit must include my name and information.
If you are completing this form for multiple children, please ensure you attach the signed affidavits for each child.
I confirm that the affidavit(s) provided are for children that live in Durham Region or attend a school in Durham Region.
- If your child does not live or attend a school in Durham Region, please use the public health unit locator tool to find your correct public health unit.

Please review the notice of collection and consent of information below to continue.

COLLECTION OF PERSONAL AND PERSONAL HEALTH INFORMATION

We collect, use and release your personal and personal health information under the authority of the Health Protection and Promotion Act R.S.O. 1990 c.H.7, s.5 and the Immunization of School Pupils Act (ISPA), R.S.O. 1990, s. 11(1) and its Regulations. This information is collected for the purpose of assessing, keeping records and reporting on the immunization status and exemptions of children going to schools in the province of Ontario. Information collected is maintained within a provincial immunization information system that is provided by the Ontario Ministry of Health. Information will be collected, used, and disclosed in accordance with the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3. Questions about this collection of information should be addressed to Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E., P.O. Box 730, ON, L1N 0B2, (905) 668-7711.

I acknowledge that I have read, understood, and accept how information will be collected, used, and disclosed by the Durham Region Health Department.

Agree

CONSENT TO THE COLLECTION OF INFORMATION

I consent to the Medical Officer of Health for the Regional Municipality of Durham electronically collecting the personal and personal health information I submit through this online form for the following purposes:

To verify and validate the submitted Statement of Conscience or Religious Belief - Immunization of Schools Pupils Act (Affidavit),
To keep an electronic record of immunization or immunization exemptions for a student as required by ISPA (if relevant),
To support any programs/services administered by any public health unit in Ontario related to preventing the spread of disease and/or the promotion and protection of the health of others in Ontario.

I acknowledge that I am providing immunization exemption information about a student as required by law. I agree to provide the information for the purposes listed above.

I acknowledge

Agree

You may be contacted by us for purposes related to the non-medical exemption information provided, such as to request clarification or follow-up regarding the information submitted. By providing your phone number, you are consenting to follow-up communication which is required to process your non-medical exemption request.

Phone number