NOTICE OF INADEQUATE IMMUNIZATION
Name of student:__________________________________________ Date:_____________________
Dear Parent or Guardian: A review of our school records indicates that your child may not be currently up to date for all immunizations. Required immunizations: (dates of doses already documented are written below. Needed doses are circled).
Polio 1. _______ 2. _______ 3. _______ 4. _______ 5. ________ Dtp/Dt/Dtap 1._______ 2. _______ 3. _______ 4. _______ 5. _______ MMR Hepatitus B Varicella 1. _______ 2. _______ 1. _______ 2. _______ 3. _______
1. _______ 2. _______ Second dose is recommended
(or physician documented chickenpox histrory)
Children who have not completed required immunizations will be excluded from school.
IT IS REQUIRED THAT YOU DO ONE OF THE FOLLOWING IMMEDIATELY:
1. Take this form to your physician or health care provider to obtain required immunizations or records. Then bring the immunization record to the school office. The Trinity County Health Department offers free immunization clinics each week.
Trinity County Health Department Weaverville, Tuesdays by appointment Hayfork, monthly by appointment (530) 623-8209 Southern Trinity Health Services Monday –Friday, by appointment (707) 574-6616
2. If your child has already received the needed immunizations, bring his/her immunization record to the school office. 3. If immunizations should be omitted or delayed for medical reasons, you may submit a letter of exemption from your child’s health care provider. Parents may choose to exempt their child for personal belief. A waiver must be signed at the school.
FOR YOUR CHILD TO REMAIN IN SCHOOL, SUBMIT THE REQUIRED RECORDS BY: Please call 623-2861 ext. 252 or ext. 255 if you have any questions.
(Rev. tcoe 6/8/06)