Guide to the Statement of Conscience or Religious Belief: Form 4897-64E

As a parent or guardian, you may want to exempt your child from required immunizations for non-medical reasons. In this case, you would complete an Ontario Government form called Statement of Conscience or Religious Belief – Immunization of School Pupils Act (Form 4897-64E). This statement must be sworn or affirmed by a notary public or commissioner of oaths. 

What is a Statement of Conscience or Religious Belief?

A Statement of Conscience or Religious Belief – Immunization of School Pupils Act (Form 4897-64E) grants children a valid exemption from immunization against ISPA’s designated diseases. This form is sometimes called a Children’s Vaccine Exemption Letter or a Children’s Vaccine Exemption Affidavit. This form grants your child a vaccine exemption, preventing the medical officer of health from suspending them for failure to immunize. This form is for non-medical reasons, such as religious beliefs or conscience. 

To receive a valid exemption, parents must complete their Statement of Conscience or Religious Belief form and have it sworn or affirmed before a notary public or commissioner of oaths. At NotaryPro, our notary publics can notarize your form online, from the comfort of your home or office.

*If you require a vaccine exemption for your child for medical reasons, you’ll want to complete the Statement of Medical Exemption form instead. 

When Do You Need a Statement of Conscience or Religious Belief?

All children and adolescents attending primary or secondary school, between the ages of 4-17, must be appropriately vaccinated by law. You would complete a Statement of Conscience or Religious Belief if you want to exempt your child or minor from required vaccinations for non-medical reasons.  

If you do not want your child to be immunized against ISPA’s designated diseases listed below, you would complete this form: 

• Meningitis (meningococcal disease)
• Diphtheria
• Poliomyelitis
• Measles
• Mumps
• Rubella
• Whooping cough (pertussis)
• Chickenpox (varicella) – required for children born in 2010 or later
• Tetanus

For more information about vaccines and Ontario’s publicly funded immunization program, click here. 

Completing Your Statement of Conscience or Religious Belief

As an applicant, you’ll need to provide your full name and contact information. Additionally, you must provide a few details about your child or adolescent, including:

• Their first and last name
• Their home address
• Their date of birth
• The name of their School
• Their grade
• The immunization(s) you would like them to be exempt from

Notarizing Your Statement of Conscience or Religious Belief

You will need the affidavit portion of your Statement of Conscience or Religious Belief sworn or affirmed by a notary public or commissioner of oaths. At NotaryPro, our licensed notary public professionals can notarize your form online, in under 7 minutes. Follow the steps below to get your form sworn or affirmed (notarized):

• Head to NotaryPro’s document portal and download the Statement of Conscience or Religious Belief form. 
• Complete everything before the section, SWORN OR SOLEMNLY AFFIRMED before me. This is the affidavit portion of the form and is to be completed before a notary public or commissioner of oaths. 
• Once your form is completed, head to our notarization platform and select Notarize (e-Sign a Document).
• Upload your completed form and get it instantly notarized via video call, or schedule a future appointment at your convenience.

Getting an Immunization Exemption for Your Child in Ontario

Once you complete your form and get it notarized, you’ll need to follow a few more steps to obtain a vaccine exemption. They include:

• Informing your local public health unit (PHU) that you wish to have your child exempted from ISPA’s required vaccines. If you don’t have the contact information for your PHU, use the Ontario Public Health Unit Locator.
• Your PHU will advise you on all steps required to obtain a valid exemption and answer any questions you may have.
  • You are required to watch this vaccine education video to ensure you are making an informed decision and are aware of immunization law.
  • Once you’ve watched the video, your PHU will provide you with a signed and dated Vaccine Education Certificate.
• Submit the original Vaccine Education Certificate and your completed, signed, and notarized Statement of Conscience or Religious Belief form to the medical officer of health at your local PHU.
  • Each PHU operates differently, so contact them to find out how to submit your documents.
  • Ensure you make copies of both of the above documents for your records, as the ministry and local PHUs do not keep records of exemptions.

Notarize Your Statement of Conscience or Religious Belief Online

If you’d like to exempt your child from immunization against ISPA’s designated diseases, you’ll need to complete a Statement of Conscience or Religious Belief – Immunization of School Pupils Act (Form 4897-64E). This statement must be sworn or affirmed before a notary public or commissioner of oaths. 

At NotaryPro, we can get your form notarized online in 7 minutes — with a licensed notary public through our secure notary platform. We also have an extensive library of legal document templates available in our document portal. 

Discover how easy online notarization can be by booking an appointment today!