KINDLY PRINT THIS FORM , SIGN IN ALL PLACES AND HAND IN TO JACKIE FOR THE REGISTRATION TO BE COMPLETE. BY ADDING YOUR EMAIL ADDRESS IN THE "FAMILY EMAIL ADDRESS" BOX IT WILL BE SENT TO YOU READY FOR PRINTING AND SIGNATURE

Under the Day Nurseries Act, Section 33, in order to attend Ontario Child Care Facilities, children must have proof of immunization against diphtheria, pertussis (whooping cough), tetanus, polio, haemophilus b, and measles, mumps and rubella.  Immunization against measles, mumps and rubella must have been given after the 1^st birthday.

Family Name

Child's Name

Mother's Name

Father's Name

Birth Date (DD/MM/YY)

Health Card Number

Sex   Male
  Female

Address

City

Postal Code

Home Tel

Mother's Work Tel

Father's Work Tel

Date Vaccines Given (DD/MM/YY)

Vaccine(s) Administered

Date Vaccines Given (DD/MM/YY)

Vaccine(s) Administered

Date Vaccines Given (DD/MM/YY)

Vaccine(s) Administered

Date Vaccines Given (DD/MM/YY)

Vaccine(s) Administered

Date Vaccines Given (DD/MM/YY)

Vaccine(s) Administered

Date Vaccines Given (DD/MM/YY)

Vaccine(s) Administered

Date Vaccines Given (DD/MM/YY)

Vaccine(s) Administered

Contact the Immunization Team at 1-877-794-1880 if:-          

• This child needs an exemption from immunization against any disease listed for medical, religious or conscience reasons, or
• This child does not have an immunization record, or
• You have any questions about this form

CHILDREN MUST BE ADEQUATELY IMMUNIZED IN ORDER TO ATTEND A CHILD CARE FACILITY

Parent's Signature

Date

Family Email  *