Fillable Emergency, Information and Immunization Record Card (Arizona Department of Health Services)

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Emergency, Information and Immunization Record Card (Arizona Department of Health Services)

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The Emergency, Information and Immunization Record Card (Arizona Department of Health Services) form is 2 pages long and contains:

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CDC/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:
Home Phone:
Date of Birth:
Sex: male female
Parent or Guardian Name:
Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional):
Contact Telephone Number:
Parent 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:
*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):___ _______
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.
G:\Forms\Emergency Information and Immunization Record Card (9/18)
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:
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
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:
mo /day/ yr
mo /day/ yr
mo /day /yr
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
be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?
No Yes
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:
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Emergency, Information and Immunization Record Card (Arizona Department of Health Services)

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Completed 14 December 2021

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