Health Questionnaire

Immunization Records

  • Immunization Record (please give specific dates (y/m/d)
  • (Please note if you have chosen not to Immunize, we require a parent letter stating such with your signature )

DaPTP& HIB (Haemophilus Influenza conjugate Vaccine)

DaPtP (Diphtheria, acelluar, Pertussis,Tetanus, & Polio vaccine)

MMR (Measles, Mumps, Rubella vaccine)

Varicella (Chicken pox)

Please Note the following:

  • DaPTP and Hib are combined in a single injection at 2, 4, 6, and 18 months of age. Varicella is now recommended at 12 months of age.
  • Please inform director of new immunization dates as they occur.
  • If you are choosing not to immunize your child/children, please contact the director to fill in a waiver form. A doctor’s note will be required.

Please provide the name of your child’s current physician and dentist if your child has been seeing one.

Please list the other children in the household:

Parents/Guardian Acknowledgement: