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Child Care Admission Profile and Immunization History

Request No: 14116 - Communications Request

Under the Child Care and Early Years Act, children attending a licensed child care facility must have up-to-date immunizations, or a valid exemption. Please fill in the following information and attach a copy of your child's immunization record. You will also need to provide a copy directly to your child care provider.

Child's first name

Child's last name

Date of birth

Gender

Male

Female

Other

Address

Postal code

Home phone number 999-999-9999

Work phone number

Ontario Health Card

Name of child care facility

Name of parent or guardian

Relation to child

Please attach your child's immunization record

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By checking this box, I acknowledge I have read, understand, and agree that the information provided in this form is correct.

Yes

This information is collected under the authority of sections 2 and 5 of the Health Protection and Promotion Act, and the Child Care and Early Years Act Part II, Section 32, 35, 72, and 73. The information will be used for the administration of public health programs. Any questions about the collection of this information should be directed to the Vaccine Preventable Disease Team manager, KFL&A Public Health, 221 Portsmouth Avenue, Kingston, Ontario, 613-549-1232 or 1-800-267-7875.