Affidavits
Statement of Conscience or Religious Belief (Immunization of School Pupils Act)
A sworn statement by a parent or guardian that Ontario’s Immunization of School Pupils Act requirements conflict with their sincerely held religious belief or conscience — used to request a non-medical school immunization exemption.
Pay only when you notarize
Word files are editable. Review any changes carefully before signing or uploading.
Also known as
- Immunization Exemption – Religious or Conscience
- Vaccine Exemption Affidavit (School)
- Statement of Conscience – Immunization of School Pupils Act
STATEMENT OF CONSCIENCE OR RELIGIOUS BELIEF
Immunization of School Pupils Act
I, ______, of ______, in the Province of Ontario, being the ______ of ______ (born ______), a pupil at ______, MAKE OATH AND SAY (or SOLEMNLY AFFIRM) as follows:
The requirements of the Immunization of School Pupils Act conflict with my sincerely held convictions based on my ______.
I am requesting an exemption from immunization for the above-named pupil for the following designated disease(s): ______.
I make this statement in respect of the above-named pupil, for the purpose of the pupil’s attendance at school.
I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.
SWORN (or AFFIRMED) before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.
_______________________________ _______________________________
A Commissioner for taking Affidavits Signature of Parent/Guardian
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Statement of Conscience or Religious Belief (Immunization of School Pupils Act)
A compact preview of this template
01Pupil Information
Pupil’s full legal name
Your full legal name
Basis for the exemption
STATEMENT OF CONSCIENCE OR RELIGIOUS BELIEF
Immunization of School Pupils Act
I, ______, of ______, in the Province of Ontario, being the ______ of ______ (born ______), a pupil at ______, MAKE OATH AND SAY (or SOLEMNLY AFFIRM) as follows:
The requirements of the Immunization of School Pupils Act conflict with my sincerely held convictions based on my ______.
I am requesting an exemption from immunization for the above-named pupil for the following designated disease(s): ______.
I make this statement in respect of the above-named pupil, for the purpose of the pupil’s attendance at school.
I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.
SWORN (or AFFIRMED) before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.
_______________________________ _______________________________
A Commissioner for taking Affidavits Signature of Parent/Guardian
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Overview
About this document
- 01
What is a Statement of Conscience or Religious Belief?
It is a sworn statement made by a parent or legal guardian under Ontario’s Immunization of School Pupils Act, declaring that the Act’s immunization requirements conflict with their sincerely held convictions based on religion or conscience.
It is used to request a non-medical exemption so a child can attend school without the otherwise-required immunizations.
- 02
When you might need one
You may need it when:
- Your child’s school or public health unit asks for proof of a non-medical exemption.
- You are declining one or more required immunizations for your child on religious or conscience grounds.
- You are enrolling a child and choosing an exemption rather than the standard immunization record.
- 03
What you’ll need to fill it in
Have ready:
- The pupil’s full legal name, date of birth, and school.
- Your full legal name and address, and your relationship to the pupil.
- The specific disease(s) or vaccine(s) you are requesting an exemption from.
- 04
How to get it notarized in Ontario
Fill in the form and download a clean, ready-to-sign PDF. Do not sign it yet — it must be signed in front of a notary public or commissioner for taking affidavits.
Book an appointment with Minute Notary. We administer your oath or affirmation, witness your signature, and apply the seal — online where eligible, or in person in Ottawa. Your school may also require a vaccine education certificate from your public health unit.
Good to know
Before you fill it in.
Short notes from our notary on this template. Worth a minute before you start.
- 01
Reviewed for use in Ontario by a notary public.
- 02
Fill it in online and download a ready-to-sign PDF — no account needed.
- 03
Sign only in front of the notary; we administer the oath and apply the seal.
Frequently asked
Questions about the Statement of Conscience or Religious Belief (Immunization of School Pupils Act)
- Do I have to sign this in front of a notary?
- Yes. This is a sworn statement (affidavit). It is only valid once you sign it in front of a commissioner for taking affidavits or a notary public, who completes the jurat and applies the seal. Do not sign it beforehand.
- Is a notarized statement all my school needs?
- Usually no. In Ontario, a non-medical exemption also requires you to complete a vaccine education session at your local public health unit and submit the education certificate alongside this commissioned statement. Check with your public health unit for current requirements.
- Do I need a separate statement for each child?
- Yes. A separate statement must be completed and sworn for each pupil.
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