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Student Immunization Form

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Student Immunization form FOR SCHOOL USE ONLY. Student Name ________________________________________ __________ ( ) Complete; booster required in ____________. ( ) In process; 8 mos. expires ______________. Birthdate ______________________Student Number ___________________ ( ) Medical exemption for __________________. ( ) Conscientious objection for ______________. Minnesota law requires children enrolled in school to be immunized against certain ( ) Parental/guardian consent ______________. diseases or file a legal medical or conscientious exemption. Parent/Guardian: You may attach a copy of the child's Immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received.

Title: Student Immunization Form - Minnesota Dept. of Health Author: Freeman, Patti Segal Subject: Form to record your child's immunizations and exemptions for MN school enrollment.

  Form, Immunization, Immunization form

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