REQUEST FOR IMMUNIZATION RECORDS REQUEST FOR IMMUNIZATION RECORDS

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					                       REQUEST FOR IMMUNIZATION RECORDS

                            Fairfield Community High School
                             School Nurse: Mrs. Cindy Halley
                                          842-
                            Phone: (618) 842-2649 ext. 233
                                             842-
                                  Fax: (618) 842-5187

How can immunization records be obtained?
By mail, fax or stopping by in person.

What is the mailing address?
Fairfield Community High School
Attn: School Nurse
300 W. King Street
Fairfield, IL 62837


Today’s Date:_______________________________________


Your last name when in school (Maiden):______________________________________


Your current last name:____________________________________________________


First Name:______________________________________________________________


Date of Birth:______________________


Year Graduated/Last year you attended:_______________________


Mail to:__________________________________________

________________________________________________

________________________________________________

________________________________________________


Fax to:___________________________________________


Signature:_________________________________________________________________(required)