IMMUNIZATION (VACCINATION) INFORMATION FOR SCHOOL
Online Child Immunization Report Form
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
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…
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