• To be completed by parent prior to entry into child care center.

  • Under the Day Nurseries Act, Section 33, "every operator shall ensure that before a child is admitted to a day nursery operated by the operator or to a location where private-home day care is provided by the operator, and from time to time thereafter, the child is immunized as recommended by the local medical officer or health."

  • Any of Diptheria, Tetanus, Pertussis, Polio, Hib, Pneumo Conjugate, Measles, Mumps, Rubella, Men C conjugate, Varicella, Hepatitus B
    - Add as many rows as necessary by clicking the plus symbol to the right of the form fields
    VaccineDate Vaccine Given 
    Add a new row

  • Call the York Region Community and Health Services Immunization Team at 1-877-794-1880 if:

    • This child needs an exemption from immunization against any disease listed for medical, religious or conscientious reasons, or
    • This child does not have an immunization record, or
    • You have any questions about this form

    This information is being collected under the authority of the Health Protection and Promotion Act, R.S.O 1990 c.H.7 for the purpose of case management and case investigations, client follow up and monitoring, contact tracing, public health administration and the provision of statistical data to the Ministry of Health and Long-Term Care. Information will be retained, used, disclosed and disposed of in accordance with the Personal Health Information Protection Act, 2004, S.O. 2004, c.3. Any questions regarding this collection may be directed to the Privacy Officer, located t 17250 Yonge Street, Newmarket, Ontario, L3Y 6Z1, and (905) 830-4444 ext. 1320