Elementary School Emergency-Info-Immunization-Card

Arizona Department of Health Services

Bureau of Child Care Licensing

Emergency, Information and Immunization Record Card

Please complete the form below. Required fields marked with an asterisk *

Child's Last Name*

Answer Required

Child's First and Middle Name *

Answer Required

Home Address (#, Street, City, State, Zip Code)*

Answer Required

Home Phone Number (111-111-1111)*

Number Required

Student's Date of Birth*

Answer Required

Sex*

Answer Required

male

female

Parent or Guardian Last Name *

Answer Required

Parent or Guardian First Name *

Answer Required

Home Address (#, Street, City, State, Zip Code)*

Answer Required

Contact Telephone Number (111-111-1111)*

Number Required

Parent or Guardian Name

Answer Required

Home Address (#, Street, City, State, Zip Code)

Answer Required

Contact Telephone Number (111-111-1111)

Number Required

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*

Answer Required

Relationship to Child*

Answer Required

Contact Telephone Number (111-111-1111)*

Number Required

Name*

Answer Required

Relationship to Child*

Answer Required

Contact Telephone Number (111-111-1111)*

Number Required

Name

Answer Required

Relationship to Child

Answer Required

Contact Telephone Number (111-111-1111)

Number Required

Name

Answer Required

Relationship to Child

Answer Required

Contact Telephone Number (111-111-1111)

Number Required

If Medical care is necessary, call Health Care Provider (A Health Care Provider is a physician, physician assistant or registered nurse practitioner.)

Health Care Provider's Name*

Answer Required

Provider's Telephone Number (111-111-1111)*

Number Required

I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her health and safety.

In case of injury or sudden illness, I request that this individual be called first.*

Answer Required

The following individual(s) may NOT remove my child from the facility.

Name(s)

Answer Required

Custody paper have been provided and are on file at the facility.

Answer Required

yes

Telephone Authorization Code (optional)

Answer Required

Immunization 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: 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:

Answer Required

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

Please attach the above document here.*

Answer Required

Choose a file or drag it here.

Please attach the student's birth certificate here.*

Answer Required

Choose a file or drag it here.

(STAFF USE ONLY) Notification of immunizations needed sent to Parent(s) or Guardian(s)

Document month, day, year here

Answer Required

(STAFF USE ONLY) Updated immunizations received and attached

Document month, day, year here

Answer Required

Medical Information

Is child allergic to food or other substances?*

Answer Required

Yes

If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs.

Answer Required

Is child usually susceptible to infections?*

Answer Required

Yes

If child is susceptible to infections, please list what precautions need to be taken.

Answer Required

Is child subject to convulsions?*

Answer Required

Yes

If child is subject to convulsions, what should be our procedure if one occurs?

Answer Required

Is there any physical condition that we should be aware of (heart trouble, foot problem, hearing impairment, hernia, etc.?)*

Answer Required

Yes

If there are any physical conditions that we should be aware of, what precautions should be taken?

Answer Required

Additional comments:

Answer Required

Other special instructions:

Answer Required

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

Parent/Guardian Signature*

Answer Required

Today's Date*

Answer Required

Please fix the highlighted areas below before submitting.

Elementary School Emergency-Info-Immunization-Card