Emergency, Information and Immunization Record Card 24-25

Arizona Department of Health Services Bureau of Child Care Licensing
Emergency, Information and Immunization Record Card
Child's Information
Child’s Full Name:*
Child's Date of Birth:*

MonthDayYear
Date
MaleFemale
Child's Full Home Address: (#, Street, City, State, Zip Code)*
Home Phone:*
Format: (000) 000-0000.
Parent/Guardian Information
First Parent or Guardian's Name:*
First Parent or Guardian's Home Address (#, Street, City, State, Zip Code)*
First Parent or Guardian's Contact Telephone Number*
Format: (000) 000-0000.
Second Parent or Guardian's Name*
Second Parent or Guardian's Home Address (#, Street, City, State, Zip Code)*
Second Parent or Guardian's Contact Telephone Number*
Format: (000) 000-0000.
Non-Parent Emergency Contact Information
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)
First Non- Parent Contact Person's Full Name*
First Non- Parent Contact Person's Telephone Number*
Format: (000) 000-0000.
Second Non-Parent Contact Person's Name*
Second Non-Parent Contact Person's Telephone Number*
Format: (000) 000-0000.
Third Non-Parent Contact Person's Name
Third Non-Parent Contact Person's Telephone Number
Format: (000) 000-0000.
Fourth Non-Parent Contact Person's Name
Fourth Non-Parent Contact Person's Telephone Number
Format: (000) 000-0000.
The following individual(s) may NOT remove my child from the facility: (If the person listed is a parent, we must have custody papers on file in the office)
Please provide a password that you would like to use to make any changes to your child's authorized pick up list via phone. This password can be numerical, a word, or phrase. This password will not be shared with anyone except the office. If you are abstaining, please write "n/a":*
Medical Contact Information
Child's Physician's Full Name (i.e. Dr. John Smith)*
Physician's Phone Number:*
Format: (000) 000-0000.
In case of injury or sudden illness, I request that this individual be called first: (i.e. Mom, Dad, etc.)*
NoYes
If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:
Yes (please fill out the Medication Consent Form, linked below)No
Food Allergy Action Plan

If your child has an allergy that requires an epipen or medication to be with them on campus in case of allergic reaction, we are required to have a Food Allergy Action Plan on file for them. Please download the Food Allergy Action Plan and have your pediatrician fill it out and reupload it. If you already have a different allergy action plan that has been filled out by your doctor, that is fine to upload instead.

Medication Consent Form

Please fill out the Medication Consent Form for any medication that may need to be administered at school (i.e. Benadryl, Epipen, Zyrtec, etc.) Be sure to fill out the medication consent form for EACH medication that you will be supplying the office with. We are required by the state to have this on file for any child who has medication that may need to be administered at school. We will also need the specific medication that the doctor lists on the Action Plan (i.e. Benadryl, etc.) here in the office. If the doctor does not list "or generic" we are required to have the name brand medication. All medication must be in the original perscription box or over the counter packaging.

If your child requires an epipen, we are required by the state to have TWO epipens here on campus in the small chance that one malfunctions when administered. These epipens must be in the original prescription box and not be expired.

You can fill out the Medication Consent Form here: https://form.jotform.com/222135240159043
Food Allergy Action Plan Upload

Cancelof
NoYes
If yes, please list precautions that need to be taken:
NoYes
If yes, specify procedure:
NoYes
If yes, list precautions
Additional comments:
Other special instructions:
Immunization Records

Please upload your child's immunization records below. This can be a photo of your child's Blue Vaccination Book or a copy directly from the physician's office. You can download a copy of your child's immunizations using this website through the State of Arizona: https://myirmobile.com/

If you need to fill our a vaccination exemption, please download the Exemption Form, fill it out and then attach it below.
Immunization Records or Exemption Upload*

Cancelof
Parent/Guardian PRINTED Name
SIGNED Name
DATE

MonthDayYear
Date
Date Enrolled

MonthDayYear
Date
CDC/SGH# or name
Imm attached
Should be Empty:

Arizona Department of Health Services Bureau of Child Care Licensing

Emergency, Information and Immunization Record Card

Child's Information

Parent/Guardian Information

Non-Parent Emergency Contact Information

Medical Contact Information