Vaccine Exemption Affidavit | Free Template

You may require a Vaccine Exemption Affidavit for a variety of reasons across several contexts. You may need this Affidavit when employers or institutions impose vaccination policies or require vaccination records. These employers and institutions include but aren’t limited to the following:

• Private employers with workplace vaccination policies;
• Universities, colleges, and post-secondary institutions with campus access or on-site housing;
• Professional programs, internships, or practicum placements;
• Regulated professions or licensing bodies;
• Healthcare-adjacent workplaces;
• Government contractors or federally regulated workplaces;
• International employers or overseas institutions; or
• Airlines, transportation providers, or travel-related organizations.

A Vaccine Exemption Affidavit outlines the reason you are requesting an exemption from a vaccine. It serves as a written record of your request and stated position. The document allows you to outline your reason(s) for requesting an exemption while confirming that the details you’ve provided are accurate.

This Affidavit enables recipient organizations to keep your request on file and follow any procedural requirements. Organizations may require it for internal review, compliance, or accommodation purposes.

Submitting an Affidavit does not guarantee a vaccine exemption will be granted or override applicable public health laws or organizational policies.

Your Vaccine Exemption Affidavit must include accurate personal information and a clear reason explaining why you are requesting an exemption. You’ll need to include the details below in your Affidavit:

• Full legal name
• Current address
• Date and location of birth
• Citizenship status
• A detailed reason for the vaccine exemption request

Depending on the recipient organization, you may need to provide supporting documentation to verify facts stated. This documentation can include:

• Proof of identity (e.g., copy of a passport or government-issued ID)
• Proof of Canadian citizenship or permanent residency
• Supporting medical documentation, if applicable

Your Vaccine Exemption Affidavit must be commissioned by an authorized official, like a notary public or commissioner of oaths. This is a necessary step, and without it, your Affidavit isn’t valid.

You can meet with a notary online to have your Affidavit commissioned in 7 minutes, from anywhere with a Wi-Fi connection.

How Commissioning Your Affidavit Works

You can commission your Affidavit online through a secure video appointment. During your online notary appointment, the following will take place:

• You’ll present a piece of valid, government-issued ID to verify your identity.
• You’ll swear or affirm that the contents of your Affidavit are true.
• You’ll confirm that you understand the document and are signing voluntarily.
• You’ll sign and date the Affidavit while a notary witnesses in real time.
• A notary signs and applies their official stamp or seal.

To learn more about the commissioning process, check out our guide.

Note: Knowingly providing false information may be considered perjury under Canada’s Criminal Code.

Depending on the organization and its applicable policies, vaccine exemption requests are commonly based on:

• Documented medical contraindications: Allergic reactions or other medical conditions where vaccination is not recommended by a healthcare professional.
• Temporary medical deferrals: Vaccinations are postponed due to a medical condition, treatment, or recovery period.
• Sincerely held religious beliefs: Vaccination conflicts with religious convictions or practices.
• Creed-based beliefs: Vaccination conflicts with sincerely held beliefs recognized under human rights legislation.
• Disability-related grounds: If vaccination requirements create barriers that call for assessment and potential accommodation.
• Participation in regulated programs or placements: Internships, practicums, or clinical settings where exemption policies differ from general workplace policies.

Note: Acceptance of a Vaccine Exemption Affidavit is entirely at the discretion of the recipient organization.