CHILD IMMUZINATION STATUS DECLARATION Community Care Facilities (that are licensed to provide care to children are required to have a copy of the immunization Status on file for each child in care, in the event that an outbreak of a communicable disease should occur. This information will assist in identifying those that may require exclusion because they are not immunized. This for has been provided to: • Assist in identifying those children who are not fully immunized and • Assist licensees in meeting Section 57(2) (a) of the Child Care Licensing Regulation.To be complete by Parent/ Guardian:(Required) Child’s name Date of Birth(Required) MM slash DD slash YYYY Complete Immunization:(Required) Record on vaccinations attached Record on vaccination unavailable Received immunization in:Year of last Vaccine(Required)(if not Canada, include country) Province City Incomplete Immunization:(Required) My child has had some vaccinations My child has no vaccinations I do not know Parent’s/ Guardian’s Printed Name(Required) Date(Required) MM slash DD slash YYYY Δ
