• Arizona Department of Health Services

    Arizona Department of Health Services Bureau of Child Care Licensing

    Emergency, Information and Immunization Record Card

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  • If Medical care is necessary, call:

  • (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)

  • 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

  • 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,

  • This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by:

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  • G:Forms/Emergency Information and Immunization Record Card (9/11)

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