Emergency Information And Immunization Record Card Template Page 2
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1
2Immunization Information
(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.)
For information regarding current immunization requirements go to:
or contact the Arizona Immunization Program Office at (602)364-3630.
One of these items must accompany the EIIR card at all times:
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
mo /day/ yr
mo /day/ yr
mo /day /yr
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:
Medical Information
Is child allergic to food or other substances?
No
Yes
If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:
Is child usually susceptible to infections and if so, what precautions need to be taken?
No
Yes
:
If yes, list precautions
Is child subject to convulsions and what should be our procedure if one occurs?
No
Yes
:
If yes, specify procedure
Is there any physical condition that we should be aware of and what precautions should
No
Yes
be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?
:
If yes, list precautions
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:
DATE:
G:\Forms\Emergency Information and Immunization Record Card (6/16)
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