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IMMUNIZATION RECORD
These requirements can be waived only if a properly signed health, religious
or personal conviction waiver is filled with the daycare.
This form is for
___________________________________________Child’s Name
Completed by ___________________________________________(Parent’s Name)
*It is anticipated that varicella vaccine or history of disease will be
required for students entering daycare and kindergarten in IMMUNIZATION
HISTORY List the MONTH, DAY, AND YEAR your child received each of the
following immunizations. DO NOT USE AN (X). If you do not have an
immunization record for this student at home, contact your doctor or public
health agency to obtain the dates.
TYPE OF VACCINE:
DTP/DTaP/DT/Td (Diphtheria, Tetanus, Pertussis (For children entering
kindergarten, at least one dose of DTP/DTaP/DT vaccine must be after the 4th
birthday. Children in grades 1-12 who have received the third or subsequent
doses after the 4th birthday meet the requirement.)
First Dose
__/__/__ mo/day/yr
Second Dose __/__/__
mo/day/yr
Third Dose __/__/__ mo/day/yr
Forth Dose __/__/__ mo/day/yr
Fifth Dose __/__/__ mo/day/yr
Polio (If child received the third dose after the 4th
birthday, further doses are not required.)
First Dose __/__/__ mo/day/yr
Second Dose __/__/__ mo/day/yr
Third Dose __/__/__ mo/day/yr
Forth Dose __/__/__ mo/day/yr
Fifth Dose __/__/__ mo/day/yr
HIB (Hemophilus Influenza B) (HIB vaccine is
only required for children in licensed day care centers.)
First Dose __/__/__ mo/day/yr
Second Dose __/__/__ mo/day/yr
Third Dose __/__/__ mo/day/yr
Forth Dose __/__/__ mo/day/yr
Fifth Dose __/__/__ mo/day/yr
Hepatitis B
First Dose __/__/__ mo/day/yr
Second Dose __/__/__ mo/day/yr
Third Dose __/__/__ mo/day/yr
MMR (Measles, Mumps, Rubella) (MMR must be received on or after 1st
birthday.)
First Dose __/__/__ mo/day/yr
Second Dose __/__/__ mo/day/yr
Varciella (Chickenpox) Note: Vaccine is needed only if your child has not
had chickenpox disease. See below.
First Dose __/__/__ mo/day/yr
Second Dose __/__/__ mo/day/yr
Has your child had Varicella (chickenpox) disease? Check the appropriate
blank and provide the year if known: ___ Yes_____________year (Vaccine not
needed) ___ NO
or Unsure (Vaccine needed)
WAIVERS: For health reason this student should not receive the following
immunizations: ________________________________________________________
(Please list above any immunizations already received). Physician Signature:
_____________________________________________________________________
For religious reasons this student should not be immunized. (Please list
above any immunizations
received)._________________________________________________
For personal conviction reasons this student should not be immunized.
(Please list above any immunizations already received). This form is
complete and accurate to the best of my knowledge.
X_______________________________________Date_____________
Signature of Parent/Legal
Guardian - Date
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