•                                     NORTHWEST ALLEN COUNTY SCHOOLS
                                                 IMMUNIZATION HISTORY
     
    Name of Student: ________________________________ Date of Birth: ___________
    School: ______________________________ Grade: _______ School Year__________
    Parent’s Name(s):__________________________________ Telephone Number: ______________
    Address: ________________________________________________________________________
    Immunizations are required at time of enrollment. Completed immunizations are required by Indiana State Law for all school children. Please have your physician record your child’s immunization history below, and return the completed form to your school. Note that the law provides for exclusion from school for failure to comply with the immunization requirements.
     

    To Be Completed By Physician/Clinic
    DTP/ DTaP _______ _______ _______ _______ _______
    OPV/IPV _______ _______ _______ ______ _______
    Td ________ _______
    MMR#1 _______ MMR#2_________ OR      Measles _______Mumps ________Rubella ______
    Hepatitis B _______ _______ _______
    Hep A (required for kindergarten through 2nd grade) _______ _______
    Varicella #1 _______ Varicella #2 _________ (two doses required for K-12th grade)
    Or Yes my child has had Chickenpox (include date) ________
    Required for 6th grade:
    Meningococcal Vaccine (MCV4) _______ Tdap ________
    Required for 12th grade:
    Meningococcal Booster (MCV4) _______ (Only 1 dose needed if first dose on or after 16th birthday)
     

    The following immunizations are not required; however, if your child has received any of these, please list them so that we can keep your child’s health record current.
    Hib _______ _______ _______ _______ _______ PCV ______ ______ ______ ______ ______
    HPV _______ _______ _______
    Tuberculin test Date ________ Result _______
    Other___________________________________________________________________________
    Health Care Provider Signature: ____________________________________ Date: ____________