Immunization information form

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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)
Date of Birth(Required)
Complete Immunization(Required)
Incomplete Immunization(Required)

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
Date
Max. file size: 2 MB.
Max. file size: 2 MB.
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