Region of Waterloo Form

Required fields are marked with asterisks (*)

Report an upcoming vaccine appointment to Public Health

For elementary students (JK-Grade 8 only) who received an ISPA suspension order and have a vaccine appointment with a health care provider after April 1, 2025:

Please complete this form to notify Public Health of your child's appointment date with a health care provider, only if the appointment is after April 1, 2025
A temporary exemption will be placed on the student's vaccine record so they will not be suspended from school

Student's Last Name

Student's First Name

Student's Middle Name

Student's Ontario Health Card number

Student's Date of Birth

Name of Parent or Guardian

Email address:

Phone number:

What is the date of the student's vaccine appointment (must be after April 1, 2025)?

Notice of collection of Personal Health Information: By completing the online reporting form, you are consenting to the collection and use of your personal health information by Region of Waterloo Public Health and Paramedic Services to maintain the provincial immunization database. For further information about this, please contact us at 519-575-4400.