Intention to Not Vaccinate
Last Name of Student Personal Health Number (PHN)Birthdate (YYYY / MM / DD)First Name of Student
School Division Teacher
Name of Parent/Guardian Relationship to Student
Home Phone Number
Cell Phone Number
Children who have not been immunized against a disease
are subject to exclusion from school in the event of an outbreak of that disease.
I, the above-named parent/guardian of the
above-named child, conrm that my child
will NOT be immunized with the following vaccine(s):
Measles, Mumps, Rubella (MMR)
Measles, Mumps, Rubella, Varicella (MMRV)
Meningococcal C Conjugate (Men-C-C) - Grade 8 and younger only
Meningococcal Conjugate ACYW (Men-C-ACYW) - Grade 9 and older only
Tetanus, Diphtheria, Pertussis (Tdap)
Tetanus, Diphtheria, Pertussis, Polio (Tdap-IPV)
Varicella (chickenpox)
Reasons for not vaccinating:
Personal information collected on this form will be used by the health authority to update the student’s immunization record under the Vaccination Status Reporting
Regulation, B.C. Reg. 146/2019. The information will be used and disclosed in accordance with the Freedom of Information and Protection of Privacy Act. Summary statistical
information may be reported to the Ministry of Health. If you have any questions about the collection and use of this personal information, contact your local public
health nurse. You may be contacted to request your participation in the evaluation of this school immunization program.
Signature of Parent/Guardian or Student Aged 19 or Older Date Signed (YYYY / MM / DD)
Please submit this form to your local Public Health Unit, which can be found atnder
Work/Alternate Phone Number
HLTH 2369 2019/10/30
I, the above-named student, being age 19 or older, conrm
that I will NOT be immunized with the following vaccine(s):
Dear Parent / Guardian / Student,
Children whose parent / guardian has indicated that their child will not be immunized will be re-
oered vaccine at future encounters, including, as a minimum:
When the child turns 10 years of age
When the child turns 13 years of age
After the age of 13, children may be asked to consent to immunization on their own behalf,
regardless of previous parent / guardian refusal. This is the law in British Columbia, known as
‘Mature Minor Consent’.
The Infants Act explains the legal position of children under 19 years of age. One of the topics
covered in the Infants Act is the health care of children, stating that children may consent to a
medical treatment on their own behalf as long as the health care provider is sure that the treatment
is in the child’s best interest, and that the child understands the details of the treatment, including
risks and benets. It is up to the health care provider to assess and ensure the child’s understanding
of the treatment.
For more information on Mature Minor Consent, visitles/infants-act-mature-minor-consent-and-immunization
Risks of Not Being Immunized
Immunization programs have signicantly reduced cases of vaccine preventable diseases in Canada.
However, vaccine preventable diseases can appear at any time in your community because these
diseases still circulate in Canada or elsewhere in the world. Your child can also be exposed to these
infections during travel. These infections are serious and can be life-threatening.
Delaying or refusing vaccines for your child also puts others at risk of illness, especially infants
who are too young to be fully immunized, people with weaker immune systems, such as people
with cancer, and people with chronic health conditions such as heart or lung disease or diabetes.
These members of our community rely for their protection on immunization of those who can be
In the event of an outbreak of a vaccine preventable disease at your child’s school, children who are
unimmunized may be excluded from attendance at school.
If your child is sick and receives medical attention, inform the health care provider that your child is
not fully immunized. This may guide diagnostic tests and precautions to avoid spread of infection to
others in the health care setting.
Communities depend on high immunization rates to keep vaccine preventable diseases from
spreading. Maintaining population immunity through immunization during childhood lowers the
risk for everyone.
For more information, see:les