Form Builder

Required fields are marked with asterisks (*)

Vaccine Education Certificate request

This questionnaire is part of the process to obtain an immunization exemption for your school-aged child(ren) for conscience or religious beliefs.
Your child(ren) must attend a school in Huron or Perth counties.
This questionnaire is to be completed after watching the Ontario Ministry of Health's Vaccine Education Video.
All fields are required.

If you require assistance, please call Huron Perth Public Health at 1-888-221-2133 ext. 3558.

By checking this box, I acknowledge that I have watched the Vaccine Education Video.

Yes

Parent/Legal Guardian First Name:

Parent/Legal Guardian Last Name:

Previous last name of parent/legal guardian (e.g. maiden name) if applicable:

Parent/legal guardian date of birth (DD/MM/YYYY):

Parent/legal guardian phone number (e.g., 555-123-4444):

Parent/legal guardian street address:

Town/Municipality:

Postal Code: