Region Of Waterloo Public Health Temporary Immunization Exemption Form

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Form
C1
REGION OF WATERLOO PUBLIC HEALTH
Temporary Immunization Exemption Form (Religious or Conscience)
for children attending a child care centre in Waterloo Region
The Child Care and Early Years Act requires all infants and children attending a child care centre be fully
immunized as recommended by the Medical Officer of Health. In Waterloo Region this includes: Diphtheria,
Tetanus, Pertussis, Polio, Measles, Mumps, Rubella and Haemophilus Influenza type B.
A temporary immunization exemption is allowed for children attending a child care centre only. When your child
attends a public, Catholic or private school, a notarized exemption will be required as per the Immunization of
School Pupils Act.
Child’s
Child’s
Last Name:
First Name:
Date of Birth:
Male
Female
Other:______________
__ __ __ __ / __ __ / __ __
Year
/ Month /
Day
Name of Parent/Guardian A:
Name of Parent/Guardian B:
Mother
Father
Guardian
Mother
Father
Guardian
Child’s Primary Address:
City:
Postal Code:
Home Phone: (
) __ __ __ - __ __ __ __
Child Care Centre:
I,_______________________________________, parent/guardian of the above named child, make oath or
solemnly affirm and say that the requirements of recommended immunization(s) conflict with my sincerely held
convictions based on my religion or conscience (please check required box or boxes):
Other:_____
Diphtheria
Pertussis
Tetanus
Polio
Hib
Measles, Mumps, Rubella
I understand that the Medical Officer of Health may order that the above named person be excluded from the
child care centre if there is an outbreak or immediate risk of an outbreak of a designated disease in the child
care centre where one of the following has not been received:
A statement of immunization or other satisfactory evidence of immunization.
A statement of medical exemption stating that immunization is unnecessary because of evidence of
immunity.
Parent/Guardian Signature: __________________________________ Date: _________________________
Witness Signature: _________________________________________ Date: ________________________
NOTICE OF PURPOSE – PERSONAL HEALTH INFORMATION
By completing this form you are consenting to the collection and use of your personal health information by Region of
Waterloo Public Health to maintain the provincial immunization database. For further information please contact the
Director of Central Resources at 519-575-4400.
164993

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