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Madison Metropolitan School District

Student Immunization Record

The form below does NOT show the immunization record we have on file for your child. Submit your child's complete record ONLY if this is your first time enrolling in an MMSD school or if your child has received a new immunization.

INSTRUCTIONS TO PARENT: Complete within 30 DAYS AFTER ADMISSION. State laws 252.04 and 120.12(16) require all public and private school students to present written evidence of immunization against certain diseases within 30 school days of admission. The current age/grade specific requirements are listed below in step 3. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver is filed by the school. The purpose of this form is to measure compliance with the law and will be used for that reason only. If you have questions on immunizations or how to complete this form, contact your child's school or local health department.

Required

STEP 1: Personal Data

Student Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format
Parent/Guardian Namerequired
First Name
Last Name

STEP 2: Immunization History

List the MONTH, DAY and YEAR your child received each of the following immunizations. If you do not have an immunization record for this student at home, contact your doctor or public health department to obtain it.

DTP/DTaP/DT/Td (Diphtheria, Tetanus, Pertussis)

Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format

Tdap (Tetanus, Diphtheria, Acellular Pertussis)

Must contain a date in M/D/YYYY format

Polio

Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format

Hepatitis B

Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format

MMR (Measles, Mumps Rubella)

Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format

Varicella (Chickenpox)

NOTE: Vaccine is needed only if your child has not had chickenpox disease. See below:

Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format

Has your child had Varicella (Chickenpox disease)? Check the appropriate box and provide the date, if known.

Varicella (Chickenpox)required
Must contain a date in M/D/YYYY format

STEP 3: Requirements

Refer to the age/grade-level requirements for the current school year to determine if your child meets the requirements.

Immunization Requirements - English

STEP 4: Compliance

PLEASE NOTE THAT INCOMPLETELY IMMUNIZED STUDENTS MAY BE EXCLUDED FROM SCHOOL IF AN OUTBREAK OF ONE OF THESE DISEASES OCCURS.

STEP 5: Agreement

I understand that if my child HAS NOT received ALL required doses of vaccine, the FIRST DOSE(S) has/have been received. I understand that the SECOND DOSE(S) must be received by the 90th school day after admission to school this year, and that the THIRD DOSE(S) and FOURTH DOSE(S), if required, must be received by the 30th school day next year. I also understand that it is my responsibility to notify the school in writing each time my child receives a dose of required vaccine.

WAIVERS: (Please list in Step 2 any immunizations already received.)

If you are submitting a waiver for your child, please print the Printable Student Immunization Record, sign and date the form (or have your child's health care provider sign and date it for a medical waiver) and return the form to your child's school.

This form is complete and accurate to the best of my knowledge.required