# Child immunization and health record form

Source: https://backpr.com/resources/templates/immunization-and-health-record-form. Last updated: 2026-10-22.

Keeps a child's vaccine dates, checkups and health screenings in one place for your childcare records, with space for a health care provider's signature.

Free download: PDF https://backpr.com/media/templates/backpr-immunization-and-health-record-form.pdf · Word https://backpr.com/media/templates/backpr-immunization-and-health-record-form.docx

> Please attach a copy of your child's official immunization record from their health care provider or your state's immunization registry, and fill out the rest of this form. If our state has its own required health form, we'll give you that too. Please tell us whenever your child gets a vaccine or has a checkup.

**Child**
- Full name: ______
- Date of birth: ______
- Parent or guardian name and phone: ______

**Health care provider**
- Child's health care provider and practice: ______
- Phone: ______
- Dentist (if your child has one): ______

**Immunizations**
Attach your child's official immunization record, or ask your child's health care provider to fill in this table with each vaccine and the date of every dose.
- [ ] Official immunization record attached
| Vaccine | Dose 1 date | Dose 2 date | Dose 3 date | Dose 4 date | Dose 5 date |
| --- | --- | --- | --- | --- | --- |

**Exemptions**
Fill this in only if your child has an exemption that our state allows, and attach the official exemption form. During an outbreak, the health department may ask that children who aren't vaccinated against that disease stay home.
- [ ] Exemption form attached
- Type of exemption and the vaccines it covers: ______

**Checkups and screenings**
- Date of last well-child checkup: ______
- Next checkup due: ______
- Health screenings and dates (such as vision, hearing, lead or developmental screening, if our state or program asks for them): ______

**Health information**
If your child has allergies, takes medicine or has other health needs, please also fill out our medical and allergy form.
- Allergies and reactions: ______
- Ongoing health conditions (such as asthma, diabetes or seizures): ______
- Medicines taken regularly: ______
- Anything else that helps us care for your child: ______

**Health care provider signature (if our state or program requires it)**
Some states require a health care provider to sign a child's health record or health assessment before the child starts childcare.
- Health care provider's printed name: ______
- Health care provider signature and date: ______

**Parent or guardian**
The information on this form is correct to the best of my knowledge. I'll tell the program when my child gets a vaccine, has a checkup or has a change in their health.
- Parent or guardian's printed name: ______
- Parent or guardian signature: ______
- Date: ______

**For program use**
- Reviewed by and date: ______
- Next vaccines or records due (date): ______
- Follow-up with the family (date and notes): ______

### How to use it
- Follow your state's licensing and health department rules on which vaccines children in childcare need, which exemptions your state accepts, which forms to use and how quickly families must turn them in. Ask your state's health department or licensing agency if you're unsure. Find your state's rules at backpr.com/resources/states.
- If a record looks incomplete, ask the family to check with their child's health care provider. Don't try to decide which vaccines a child needs yourself.
- Note each child's next due date, so you can remind families before their records go out of date.
- Store records securely, because they contain health information. Share them only with staff who need them and with the health department or licensing agency when the law requires it.

**Which vaccines does a child need to attend daycare?**
It depends on your state. Each state sets its own immunization requirements for childcare and decides which exemptions it accepts. Check with your state's health department or licensing agency, and ask families to talk with their child's health care provider about their child's vaccines.

**Can we use this form instead of our state's immunization form?**
Only if your state allows it. Many states have an official immunization certificate or child health form that childcare programs must keep on file. Use this form alongside it to track checkups, screenings and due dates in one place.

Free to use and change, but not legal or medical advice. Check your state's licensing rules and your insurer's requirements, and have a lawyer review any consent or waiver language.