IMMUNIZATION (VACCINATION) INFORMATION FOR SCHOOL
Online Child Immunization Report Form
Dear Parent/Guardian:
Please complete and print a copy for the school record before submitting the online version to
Vancouver Coastal Health (VCH). The information you provide will be used by VCH to keep a record of
your child’s immunization history, to offer further immunizations based on this history and to respond
to an infectious disease outbreak if it occurs in a school.
How to submit an online version of your child’s records directly to VCH:
1) Save this form to your computer/device
2)
Open form with Adobe Acrobat or Reader to enable all buttons to function correctly
4) Choose the Submit button below that best matches where your child lives
5) Attach a digital photo or scan of your child’s vaccination record(s) to the email, and Send.
CHILD INFORMATION Today’s Date:
School Name: Grade:
Child’s Name: (Last) (First) (Preferred)
Date of Birth: __________________ Sex of child:
Place of Birth: City Province Country
Child’s (BC) Personal Health Card #
Home Address: Suite/Apt: Street: ____
City: Postal Code:
Physician/Health Care Provider: Office Phone #
PARENT/GUARDIAN INFORMATION: Please provide contact information for at least one parent/guardian, so that
a public health nurse can reach you if clarification or confirmation of any information is needed.
Primary: Name: Home: # Mobile: #
Work: # Email Address:
Alternate: Name: Home: # Mobile: #
Work: # Email Address:
CHILD’S VACCINATION INFORMATION
Please attach your child’s vaccine history record(s) with this form:
• BC Child Health Passport or other vaccination record (in the original language and in a translated English version).
• Write your child’s name and date of birth on each page.
• Tick here if you do not have a record of your child’s vaccination history:
Submit to: Vancouver Submit to: North Shore Submit to: Coastal Rural * Submit to: Richmond
*Coastal Rural includes: Sunshine Coast, Powell River, Sea to Sky, Bella Bella, and Bella Coola
VCH.VC.0137 Fillable Form | FEB. 2019 Please turn over for important information…
3)
Complete all fields and save to your computer, or print a hard copy for your records
Note: If you choose the wrong Submit button, your record will be forwarded to the correct location
