Section 57(2) (a) of th Child Care Licensing Regulation requires licensed child care programs to have a record of each child’s immunization status. The completion of this form meets the requirement to maintain a record of children’s immunization status and will assist in identifying those that may require exclusion in the event of an outbreak of a communicable disease because they are not immunized.To be completed by Parent/Guardian of:Child's Name(Required) Child’s Name Date of Birth(Required)Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Complete Immunization(Required) Record of vaccinations attached Record of vaccinations anavailable Incomplete Immunization(Required) My child has had some vaccinations My child has had no vaccinations I do not know If available, please attach a photocopy of your child’s vaccination record to this form. For example: BC Child Health Passport OR immunization record either in English or any language. Ensure your child’s name and date of birth are written on each page.Parent/Guardian Printed Name Child’s Name DateYear20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Parent/Guardian SignatureMax. file size: 2 MB.Attach your child’s vaccine history record(s)Max. file size: 2 MB.
