"Emergency, Information and Immunization Record Card" - Arizona

Emergency, Information and Immunization Record Card is a legal document that was released by the Arizona Department of Health Services - a government authority operating within Arizona.

Form Details:

  • Released on September 1, 2018;
  • The latest edition currently provided by the Arizona Department of Health Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arizona Department of Health Services.

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Download "Emergency, Information and Immunization Record Card" - Arizona

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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:
Health Care
Provider*
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
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:
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):___
_______
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:
Health Care
Provider*
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
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:
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):___
_______
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:
or contact the Arizona Immunization Program Office at (602)364-3630.
www.azdhs.gov/phs/immun/index.htm
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
mo /day/ yr
mo /day/ yr
mo /day /yr
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:
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
No
Yes
be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?
:
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:
G:\Forms\Emergency Information and Immunization Record Card (9/18)
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