Child Care Immunization Record "*" indicates required fields COMPLETE AND RETURN TO CHILD CARE CENTER. State law requires all children in child care centers to present evidence of immunization against certain diseases within 30 school days (6 calendar weeks) of admission to the child care center. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver is filed with the child care center. See “Waivers” below. If you have any questions about immunizations, or how to complete this form, please contact your child’s child care provider or your local health department.PERSONAL DATAChild’s Name* First Last Date of Birth* MM slash DD slash YYYY Telephone Number*Name of Parent/Guardian/Legal Custodian* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country IMMUNIZATION HISTORYList the MONTH, DAY AND YEAR the child received each of the following immunizations. If you do not have an immunization record for this child, contact your doctor or local public health department to obtain the records.Diphtheria-Tetanus-Pertussis (Specify DTP, DTaP, or DT)*NoneFirst DoseSecond DoseThird DoseFourth DoseFifth DoseFirst Dose MM slash DD slash YYYY Second Dose MM slash DD slash YYYY Third Dose MM slash DD slash YYYY Fourth Dose MM slash DD slash YYYY Fifth Dose MM slash DD slash YYYY Polio*NoneFirst DoseSecond DoseThird DoseFourth DoseFirst Dose MM slash DD slash YYYY Second Dose MM slash DD slash YYYY Third Dose MM slash DD slash YYYY Fourth Dose MM slash DD slash YYYY Hib (Haemophilus Influenzae Type B)*NoneFirst DoseSecond DoseThird DoseFourth DoseFirst Dose MM slash DD slash YYYY Second Dose MM slash DD slash YYYY Third Dose MM slash DD slash YYYY Fourth Dose MM slash DD slash YYYY Pneumococcal Conjugate Vaccine (PCV)*NoneFirst DoseSecond DoseThird DoseFourth DoseFirst Dose MM slash DD slash YYYY Second Dose MM slash DD slash YYYY Third Dose MM slash DD slash YYYY Fourth Dose MM slash DD slash YYYY Hepatitis B*NoneFirst DoseSecond DoseThird DoseFirst Dose MM slash DD slash YYYY Second Dose MM slash DD slash YYYY Third Dose MM slash DD slash YYYY Measles-Mumps-Rubella (MMR)*NoneFirst DoseSecond DoseFirst Dose MM slash DD slash YYYY Second Dose MM slash DD slash YYYY Varicella (chickenpox) vaccine Vaccine is required only if the child has not had chickenpox disease.*NoneFirst DoseSecond DoseFirst Dose MM slash DD slash YYYY Second Dose MM slash DD slash YYYY Has the child had Varicella (chickenpox) disease? Check the appropriate box and provide the year if known.* Yes (Vaccine is not required) No or Unsure (Vaccine is required) YearREQUIREMENTSThe following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these requirements at child care entrance. Children who reach a new age/grade level while attending this child care must have their records updated with dates of additional required doses. AGE LEVELS NUMBER OF DOSES 5 months through 15 months 2 DTP/DTaP/DT 2 Polio 2 Hib 2 PCV 2 Hep B 16 months through 23 months 3 DTP/DTaP/DT 2 Polio 3 Hib1 3 PCV2 2 Hep B 1 MMR3 2 years through 4 years 4 DTP/DTaP/DT 3 Polio 3 Hib1 3 PCV2 3 Hep B 1 MMR3 1 Varicella At Kindergarten entrance 4 DTP/DTaP/DT 4 4 Polio 3 Hep B 2 MMR3 2 Varicella 1. If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or after, no additional doses are required. Minimum of one dose must be received after 12 months of age (Note: a dose 4 days or less before the first birthday is also acceptable). 2. If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months of age or after, no additional doses are required. 3. MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1st birthday is also acceptable). 4. Children entering kindergarten must have received one dose after the 4th birthday (either the 3rd, 4th or 5th) to be compliant (Note: a dose 4 days or less before the 4th birthday is also acceptable). COMPLIANCE DATA AND WAIVERSIF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the child care center), OR IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to child care center).Checkbox 1 Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been received. I, understand that it is my responsibility to obtain the remaining required doses of vaccines for this child WITHIN ONE YEAR and to notify the child care center in writing as each dose is received. NOTE: Failure to stay on schedule or report immunizations to the child care center may result in court action against the parents and a fine of up to $25.00 per day of violation.Checkbox 2 For health reasons this child should not receive the following immunizations: (List in IMMUNIZATION HISTORY any immunizations already received) Immunizations the child should not receive Checkbox 3 For religious reasons this child should not be immunized. (List IMMUNIZATION HISTORY any immunizations already received) Checkbox 4 For personal conviction reasons this child should not be immunized. (List in IMMUNIZATION HISTORY any immunizations already received) SIGNATURETo the best of my knowledge, this form is complete and accurate.SIGNATURE - Parent, Guardian or Legal Custodian* Date Signed* MM slash DD slash YYYY
