immunization

Arizona Department of Health Services

Arizona Department of Health Services Bureau of Child Care Licensing

Emergency, Information and Immunization Record Card
Child's Name
Date Enrolled

Month Day Year
Date
Updated

Month Day Year
Date
Home Address (#, Street, City, State, Zip Code)
Date Disenrolled

Month Day Year
Date
Home Phone
Date of Birth

Month Day Year
Date
Child's Sex

female male
Mother or Guardian Name
Home Address (#, Street, City, State, Zip Code)
Cell Phone (optional)
Contact Telephone Number
Father or Guardian Name
Home Address (#, Street, City, State, Zip Code)
I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted: Pursuant to R9-5-304.B, at least two contact persons are required
I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted: Pursuant to R9-5-304.B, at least two contact persons are required
Name
Contact Telephone Number
Name
Contact Telephone Number
Name
Contact Telephone Number
Name
Contact Telephone Number
If Medical care is necessary, call:
Provider
Name
In case of injury or sudden illness, I request that this individual be called first
The following individual(s) may NOT remove my child from the facility.
Custody papers have been provided and are on file at the facility.

yes no
Telephone Authorization Code (optional)
(A licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and Immunization Record card

Copy of current official documented immunization record attached

Religious Beliefs exemption form signed by parent/guardian attached

Medical Exemption form signed by physician and parent/guardian attached

Signed Laboratory Proof of Immunity form attached

Notification of immunizations needed sent to Parent(s) or Guardian(s)
mo/day/yr
mo/day/yr
mo/day/yr
Updated immunizations received and attached:

For information regarding current immunization requirements go to: www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630.

One of these items must accompany the EIIR card at all times:

Is child allergic to food or other substances?

If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction oc r
S

No Yes cu No No Yes No Yes
Is child usually susceptible to infections and if so, what precautions need to be

taken? If yes, list precautions:

Is child subject to convulsions and what should be our procedure if one

occurs? If yes, specify procedure:

Is there any physical condition that we should be aware of and what precautions

should be taken (heart trouble, foot problem, hearing impairment, hernia, etc? If yes,
Additional comments
Other special instructions
This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by:
Parent/Guardian PRINTED Name
SIGNED Name

Clear
DATE

Month Day Year
Date
G:Forms/Emergency Information and Immunization Record Card (9/11)
Should be Empty:

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