Name of Student: ________________________________ Date of Birth: ___________

School: ______________________________ Grade: _______ School Year__________

Parent's Name(s):__________________________________ Telephone Number: ______________

Address: ________________________________________________________________________

Immunizations are required at time of enrollment. Completed immunizations are required by Indiana State Law for all school children. Please have your physician record your child's immunization history below, and return the completed form to your school. Note that the law provides for exclusion from school for failure to comply with the immunization requirements.

To Be Completed By Physician/Clinic

DTP/ DTaP _______ _______ _______ _______ _______

OPV/IPV _______ _______ _______ ______ _______

Td ________ _______

MMR#1 _______ MMR#2_________ OR Measles _______Mumps ________Rubella ______

Hepatitis B _______ _______ _______

Hep A (required for kindergarten through 2nd grade) _______ _______

Varicella #1 _______ Varicella #2 _________ (two doses required for K-12th grade)

Or Yes my child has had Chickenpox (include date) ________

Required for 6th grade:

Meningococcal Vaccine (MCV4) _______ Tdap ________

Required for 12th grade:

Meningococcal Booster (MCV4) _______ (Only 1 dose needed if first dose on or after 16th birthday)

The following immunizations are not required; however, if your child has received any of these, please list them so that we can keep your child's health record current.

Hib _______ _______ _______ _______ _______ PCV ______ ______ ______ ______ ______

HPV _______ _______ _______

Tuberculin test Date ________ Result _______

Other___________________________________________________________________________

Health Care Provider Signature: ____________________________________ Date: ____________