Affidavits
Statement of Conscience or Religious Belief (Immunization of School Pupils Act)
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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