Immunisation Information Request Form

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

Child's Family Name (Surname) (required)

Child’s First Name (Christian name) (required)

Date of Birth (required)

Gender (required)

Female

Male

Other

Preferred Contact Number(required)

Preferred Contact Number Type (required)

Home

Work

Mobile

Address (required)

Email Address (required)

Medicare Card Number(required)

Parent Name or Contact Person (required)

Title

Given Name (required)

Family/Surname (required)

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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Acknowledgement of Traditional Custodians

Wyndham City Council recognises Aboriginal and Torres Strait Islander peoples as the first Peoples of Australia. We acknowledge the Bunurong and Wadawurrung Peoples as Traditional Owners of the lands on which Wyndham City operates. The Wadawurrung and Bunurong Peoples have and always will belong to the Werribee Yalook (river), creeks, stars, hills and red clay of this Country. We pay respect to their Ancestors and Elders who always have, and always will, care for Country and community today and for future generations.