I, ______________________________, give (name of school) _____________________

permission to release the following information concerning my child ______________________________

to the Indiana State Department of Health's Children and Hoosiers Immunization Registry Program (CHIRP):

Name, address, immunization dates, gender, school and date of birth.

I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me or my child of my child's immunization status or that an immunization is due according to recommended immunization schedules.

I understand that my child's information may be available to the immunization data registry of another state, a healthcare provider or a provider's designee, a local health department, an elementary or secondary school, a child care center, the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning, a licensed child placing agency, and a college or university. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3.

I hereby consent to the release of such information.

Printed Child's Name _____________________________ Grade Level __________________________

Administrative Office:

13119 Coldwater Road Fort Wayne, Indiana 46845

Phone 260-637-3155 Fax:260-637-8355 Website: www.nacs.k12.in.us