School · Ontario form
4897-64E Fillable Form: Statement of Conscience or Religious Belief
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Also known as: Vaccine Exemption Affidavit Ontario · ISPA Non-Medical Exemption · Statement of Conscience School · Form 4897-64 · Religious Exemption Form Ontario
Contents
CONTENTS
What the statement is
Ontario's Immunization of School Pupils Act asks every pupil in elementary and secondary school to show proof of immunization against the diseases the Act lists, or to have a valid exemption. Form 4897-64E is the provincial form for an exemption on grounds of conscience or religious belief. It is an affidavit: the parent or guardian swears or affirms it before a commissioner for taking affidavits.
Page 1 identifies the pupil and the parent. Page 2 is the affidavit itself, with the statements the parent confirms and the choice between an exemption from all the diseases or only from some of them. The current edition is dated 2025/04.
The two steps before you file
The form itself lists them. First, the parent completes the immunization education session required by the Act; your public health unit tells you how, and you receive a certificate. Second, the parent completes this statement and swears it before a commissioner. Both the certificate and the sworn statement go to the medical officer of health of the local public health unit, not to the school.
The statement confirms that the parent understands the medical officer of health may exclude the pupil from school during an outbreak, so it is worth reading page 2 in full before you swear it.
What to write on the form
| On the form | What to write |
|---|---|
| Pupil information | Name and date of birth as on school records, home address, school and grade |
| Parent or legal guardian | The person who swears the statement, with a phone number the health unit can use |
| "I, ..." on page 2 | Printed for you from the parent's name |
| All diseases or some | Tick one; for some, tick each disease separately |
| Sworn or solemnly affirmed before me | Left for the commissioner |
Two or more children
Each pupil needs their own statement. After you fill in the first one, use "+ Add a document" on the booking page and choose this form again: your details as the parent are copied, and you enter the next child. All the statements are sworn on one call.
Why a statement is sent back
- No education session certificate. The health unit expects the certificate with the statement.
- Both boxes ticked. Choose either all diseases or a list of specific diseases, not both.
- Signed without a commissioner. The statement must be sworn or affirmed before a commissioner, who completes the bottom of page 2.
- Sent to the school. It goes to the local public health unit.
Swearing it by video
Book and Sign attaches the statement to your appointment. On the call the commissioner checks your photo ID, you swear or affirm and sign on screen, and the commissioner completes the jurat. The sworn statement is emailed to you, ready to submit to your public health unit.
Already have it filled in?
Upload your own copy when you book and sign it with us by video.
FAQ
Who can swear the statement?
The pupil's parent or legal guardian, as named on page 1 of the form.
Does the commissioner discuss vaccines with me?
No. We do not give medical or legal advice. We verify your identity and commission the statement.
Is this the form for child care?
No. Licensed child care uses a different form under the Child Care and Early Years Act. This one is for school pupils.
Will my health unit accept a statement sworn by video?
Ontario allows affidavits to be commissioned by video. If you are unsure, ask your health unit before you book.
Can I swear statements for two children on one call?
Yes. Add a statement for each child to the same booking.
Can I download the filled form?
No. It is attached to your booking and sworn at your video appointment; the commissioned PDF is emailed to you afterwards.
We don't provide legal advice.