Free template
Immunization Record Form for Daycare — Free Digital Template
This is an immunization record form for daycare: the parent uploads a photo or PDF of the child’s immunization record — the state certificate where one exists — records the date of the most recent dose, notes any medical or religious exemption with its documentation, and attests the record is current. The record lands in the child’s file with a date to follow up. Free, and every field is editable.
No credit card. Every field is editable once it is in your account.
Last updated September 5, 2026
Enrollment packet — preview
4 sections · 16 fields · nothing here is submitted
Child
Child's full name (required)
Date of birth (required)
Parent or guardian name (required)
Parent or guardian phone (required)
Immunization record
Upload the immunization record (required)
A photo of the card or the state certificate is fine. Use your state’s official certificate where one exists.
Immunizations are up to date for the child’s age (required)
- Yes
- No — appointment scheduled
- Exemption on file
Date of most recent immunization
Date of next scheduled immunization (if any)
Primary care provider — name and phone
Exemption (if any)
Type of exemption
- None
- Medical
- Religious or personal (where your state allows)
Upload exemption documentation
Use your state’s exemption form where one exists.
Expiration or review date on the exemption (if any)
Attestation
I attest that the record uploaded is my child’s current immunization record (required)
I will provide an updated record after each new immunization (required)
Parent or guardian signature (required)
Date signed (required)
What's inside, and why each part is there
Requirements vary by state — check your state's licensing requirements before you send this to a family.
01 · Child
Immunization records are matched to a child by name and date of birth, which is also how the state registry looks them up.
02 · Immunization record
The most common reason a child’s file is marked incomplete at inspection is a missing immunization record — the parent meant to bring the card in and never did. A photo from a phone closes the gap the same day.
03 · Exemption (if any)
Exemption rules and forms are set by each state, and most require the exemption to be documented on the state’s own form. Programs are often required to keep a list of unimmunized children for exposure notices.
04 · Attestation
The parent’s attestation that the record is current, with a date, is what you point to when the follow-up date arrives.
Common questions
Does this replace my state’s immunization certificate?
No. Where a state issues an official certificate (Florida’s DH 680, South Carolina’s Certificate of Immunization, and others), that document is what licensing wants to see. This form is how the parent gets it to you — as a photo from a phone — and how you track the date it was received and when to ask for an update.
How soon after enrollment does a daycare need the immunization record?
It varies by state; 30 days after the first day is a common window, and some states require it before the child attends. Your state page on this site gives the rule and the source.
What about exemptions?
Every state allows medical exemptions and many allow religious or personal ones, nearly always on a state form. This template records the type, takes the documentation as an upload, and captures any review date so the exemption itself doesn’t quietly expire.
Can I set a reminder for the next dose?
Yes. The record lands in the child’s file with the dates you collected; if you keep child files in Records, the next-immunization date becomes an expiring item you get reminded about.
The AI builds this packet into your account, ready to edit and send.
Informational template — enrollment requirements vary by state; not legal advice. Check your state's licensing requirements for what your program must collect.