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CHILD’S IMMUNIZATION RECORD

Child’s Name_________________________ DOB:_______________

Vaccine

1st dose

2nd dose

3rd dose

4th dose

5th dose
DTP,Dtap, DT, TD          
POLIO (OPV, IPV)          
MMR          
HAEMOPHILUS INFLUENZA B (HIB)          
HEPATITUS B recommended but not required, enter if given          
VARICELLA (Chicken pox) not required, enter if given          

Vermont child care regulations require that each child enrolled in child care must be immunized appropriate to age for        DPT, polio, MMR, and HIB. However no child is required to be immunized if immunizations are medically contradicted    or against a family’s religious or moral beliefs, but an exemption form then must be filed at the child care program.

___________________________________________________                                                                                                                  Name/Title of person completing form

___________________________________________________                                                                                                    Date received by child care program

ADMISSION REQUIREMENT: One of the following must be presented when your preschool-age child is admitted to the preschool facility or within one week of admission. Check to indicate the option you select:

__________ Doctor’s Statement: I have examined the above-named child within the past year and find that he/she is physically able to take part in the day care program.

                                                                                                                                                                                                      ________________________________________________________                                                                                                                              Physician’s Signature Date

__________ A copy of the medical screening form of the Early and Periodic Screening, Diagnosis, and treatment (EPSDT) Program If no referral for further diagnosis and treatment is indicated.

__________ A form or written statement from a health service or clinic.

 

If you do not have any of the above:

Parents Statement: My child has been examined within the past year by a licensed physician and is able to participate in the school program:

Name and Address of Physician OR address of EPSDT Screening Site.

______________________________________________________________________________________

Within the next 12 months I will obtain a physician’s statement, a copy of the medical screening form from the ESDPT Program, or a form or statement from a health service or clinic and will submit it to the preschool facility, OR My child has an appointment for a physical examination:

 

                    _____________________________________________________________________________________                   Date:                         Name and Address of Physician OR Address of EPSDT Screening Site

 

I will submit the physician’s statement, EPSDT form, or health service or clinic form to the preschool facility following the examination.

                                                                                                                                                                                                                                ________________________________________________________                                                                                                                                 Signature—Parent or Legal Guardian                       Date   

NOTE: If medical diagnosis and treatment and/or immunization and TB testing conflict with your religious beliefs, you must sign an affidavit to the effect and attach it to this form. If immunization and/or TB testing would be injurious to your child or family, you must obtain a certificate (signed by a physician) to that affect and attach it to this form.

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