Region of Waterloo Form

Required fields are marked with asterisks (*)

Report upcoming vaccation appointment to Public Health

Use this form to notify Public Health of your child's appointment date (if after May 1, 2024) for secondary students who received a suspension order. A temporary exemption can be placed on the student's record so they won't be suspended.

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 (of student over 16 years old, or parent if student under 16):

Phone number:

What is the date of the student's vaccine appointment?

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.