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Vancouver Coastal Health
Immunization Form

Please Complete and submit this form

Dear Parent/Guardian:

All childcare facilities in BC are required by law under the Community Care and Assisted Living Act to keep a record of each child’s immunization history. These records are required to be made available to Vancouver Coastal Health Authority (VCH) medical health officers for public health programs. The information you provide on this form will be used to update your child’s health record at VCH in order that: medical health officers may respond if a disease outbreak occurs in your childcare facility; public health staff can recommend immunizations which your child may be missing; and VCH is able to provide better care to your child as part of its public health programs.


PART A: CHILD AND FAMILY INFORMATION
Facility name:
Child’s surname
Child’s given name
Child’s preferred name
Child’s sex Birthdate: Day:    Month:    Year:
Place of birth:
City
Province
Country
Child’s personal health number (BC Care Card)
Home address
Postal code
Home phone
e-mail
Father's name    
Daytime Phone
Mother's Name    
Daytime Phone
Guardian's Name    
Daytime Phone
Health care provider's name
Health care provider phone

PART B: CHILD'S VACCINATION INFORMATION

Has your child had chickenpox disease at 12 months of age or older?

Yes No

1. Children who have not had chickenpox disease at 12 months of age or older need chickenpox (Varicella) vaccine.

2. ATTACH A PHOTOCOPY of your child's vaccination records to this form. For example: BC Child Health Passport OR immunization record. Attach a copy of the original record as it appears in English or any language. Translations not required. Ensure your child's name and date of birth are written on each page.

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