Emergency Information And Immunization Record Card
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2CDC/SGH# or name:____________________
Arizona Department of Health Services
Bureau of Child Care Licensing
Emergency, Information and Immunization Record Card
Child’s Name:
Date Enrolled:
Updated:
Home Address (#, Street, City, State, Zip Code):
Date Disenrolled:
Date of Birth:
Home Phone:
Sex:
male
female
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):
Cell Phone (optional):
Contact Telephone Number:
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:
Name:
Contact Telephone Number:
Health Care
Provider*
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
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:
Name(s):
Custody papers have been provided and are on file at the facility.
yes
no
Telephone Authorization Code (optional):___
_______
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Parent category: Life