Immunisation Information Request Form

Privacy Collection Statement

Your and your child’s personal information is being collected by Wyndham City Council for the purpose of administering your Immunisation Information Request. The information will be stored in Council’s Customer Database and used to identify you when communicating with Council and for delivery of services and information. Dependent upon the request submitted, your details may be recorded at the Australian Immunisation Register and/or Central Immunisation Records Victoria (CIRV). Your and your child’s personal information will be handled in accordance with the Privacy and Data Protection Act 2014 (Vic). For further information about how your personal information is handled, please visit Council’s Privacy Policy.

PLEASE ALLOW 14 BUSINESS DAYS FOR THIS REQUEST TO BE COMPLETED.

Child's Family Name (Surname)

Child’s First Name (Christian name)

Date of Birth

Gender

Female

Male

Other

Preferred Contact Number

Preferred Contact Number Type

Home

Work

Mobile

Address

Email Address

Medicare Card Number

Parent Name or Contact Person

Title

Given Name

Family/Surname

If Vaccinations administered overseas – what Country?

Reason for Request (i.e. Centrelink, School Entry, etc)

List any other details/information you think council may require to help process this request.

Upload copies of all child's previous immunisation records

One file only.
10 MB limit.
Allowed types: txt pdf doc docx xls jpg png.

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