Immunization Education Session Completion Form : Public Health Sudbury & Districts

Notify Public Health that you have completed the Immunization Education Session by filling out the form below. If you are seeking an exemption for more than one child, please complete a form for each child. If you have additional questions or are unable to complete this form, please contact us.

URL

This field is for validation purposes and should be left unchanged.

Parent or guardian full name(Required)

First Last

Parent or guardian phone number(Required)

Parent or guardian email address(Required)

Confirm email address(Required)

Child’s full name

First Last

Child's date of birth(Required)

Child's Ontario Health Card Number

Child's address(Required)

Street Address City Province Postal code

Name of child's school(Required)

Untitled(Required)

As the parent or guardian of the child listed above; I confirm that I have watched the entire Vaccine Education video. I understand that watching the video is a requirement of the Ontario Ministry of Health.

Untitled

If your child is 16 years of age or older: my child has given me permission to submit this form on their behalf.

Your privacy

Personal information contained on this form is collected under the authority of one or more of the following (as amended): the Health Protection and Promotion Act, R.S.O. 1990 ; the Immunization of School Pupils Act, R.S.O.1990 ; the Regulated Health Professions Act, 1991, S.O. 1991 ; and is in compliance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990 and the Personal Health Information Protection Act, 2004, S.O. 2004 . This information is used to ensure that all appropriate personal care and public health services are provided, and that necessary statistics are kept.

Questions about this collection should be directed to the Privacy Officer at Public Health Sudbury & Districts, 1300 Paris Street, Sudbury, ON P3E 3A3, 705.522.9200 (toll-free 1.866.522.9200).

This page was last updated September 28, 2026