Immunization Form – EXCEL CHILDCARE CENTER

1st visit – 2 months of age: Date ( yy / mm / dd )

2nd visit – 2 months after 1st visit:

3rd visit – 2 months after 2nd visit: Date ( yy / mm / dd )

4th visit – 12 months of age: Date ( yy / mm / dd )

Measles
Mumps
Rubella
Meningococcal C

5th visit – 12 months after 3rd visit: Date ( yy / mm / dd )

4 – 6 years of age: Date ( yy / mm / dd )

Other Immunizations :

I authorize the childcare provider to obtain the following services for this child as necessary: Physician and/or Ambulance in the event of an emergency. NOTE: If there is a custody agreement in effect, please, give details as they relate to the child in care and attach a copy to this form

Signature of Parent/Guardian | Signature of Child Care Provider