Common use of Immunization Information Clause in Contracts

Immunization Information. licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and Immunization Record card.) For information regarding current immunization requirements go to: ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇/▇▇▇▇▇/▇▇▇▇▇.▇▇▇ or contact the Arizona Immunization Program Office at (▇▇▇)▇▇▇-▇▇▇▇. One of these items must accompany the EIIR card at all times: Copy of current official documented immunization record attached Religious Beliefs exemption form signed by parent/guardian attached Medical Exemption form signed by physician and parent/guardian attached Signed Laboratory Proof of Immunity form attached Notification of immunizations needed sent to Parent(s) or Guardian(s): mo /day/ yr mo /day/ yr mo /day /yr Updated immunizations received and attached: mo /day/ yr mo /day/ yr mo /day /yr Is child allergic to food or other substances? No Yes Is child usually susceptible to infections and if so, what precautions need to be taken? No Yes If yes, list precautions: Is child subject to convulsions and what should be our procedure if one occurs? No Yes If yes, specify procedure: Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)? No Yes If yes, list precautions: Additional comments: Other special instructions: This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by: G:\Forms\Emergency Information and Immunization Record Card (6/16) Select from list Student Name School Name Date of Birth Grade Has your child ever had chickenpox? (please circle one answer) Yes (go to #1) No (go to #2) Don’t Recall (go to #1)

Immunization Information. licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and Immunization Record card.) For information regarding current immunization requirements go to: ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇/▇▇▇▇▇/▇▇▇▇▇.▇▇▇ or contact the Arizona Immunization Program Office at (▇▇▇)▇▇▇-▇▇▇▇. One of these items must accompany the EIIR card at all times: Copy of current official documented immunization record attached Religious Beliefs exemption form signed by parent/guardian attached Medical Exemption form signed by physician and parent/guardian attached Signed Laboratory Proof of Immunity form attached Notification of immunizations needed sent to Parent(s) or Guardian(s): mo /day/ yr mo /day/ yr mo /day /yr Updated immunizations received and attached: mo /day/ yr mo /day/ yr mo /day /yr Is child allergic to food or other substances? No Yes Is child usually susceptible to infections and if so, what precautions need to be taken? No Yes If yes, list precautions: Is child subject to convulsions and what should be our procedure if one occurs? No Yes If yes, specify procedure: Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)? No Yes If yes, list precautions: Additional comments: Other special instructions: This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by: G:\Forms\Emergency Information and Immunization Record Card (6/16) Select from list Student Name School Name Date of Birth Grade Has your child ever had chickenpox? (please circle one answer) Yes (go to #1) No (go to #2) Don’t Recall (go to #19/18)

Immunization Information. licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and Immunization Record card.) For information regarding current immunization requirements go to: ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇/▇▇▇▇▇/▇▇▇▇▇.▇▇▇ or contact the Arizona Immunization Program Office at (▇▇▇)▇▇▇-▇▇▇▇. One of these items must accompany the EIIR card at all times: Copy of current official documented immunization record attached Religious Beliefs exemption form signed by parent/guardian attached Medical Exemption form signed by physician and parent/guardian attached Signed Laboratory Proof of Immunity form attached Notification of immunizations needed sent to Parent(s) or Guardian(s): mo /day/ yr mo /day/ yr mo /day /yr Updated immunizations received and attached: mo /day/ yr mo /day/ yr mo /day /yr Is child allergic to food or other substances? No Yes Is child usually susceptible to infections and if so, what precautions need to be taken? No Yes If yes, list precautions: Is child subject to convulsions and what should be our procedure if one occurs? No Yes If yes, specify procedure: Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)? No Yes If yes, list precautions: Additional comments: Other special instructions: This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by: G:\Forms\Emergency Information and Immunization Record Card (6/169/18) Select from list Student 1695 N Country Club Rd. Tucson, AZ 85716 ⬩ ▇▇▇-▇▇▇-▇▇▇▇ ⬩ ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ ⬩ ▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ Child’s Name School Name Date of Birth Grade Has your child ever had chickenpox? (please circle one answer) Yes (go to #1) No (go to #2) Don’t Recall (go to #1)First Middle Last Parent/Guardian _ Parent/Guardian _ Signature Signature