Lewis Cass Early Learning Academy
Release Education Immunization Records to CHIRP

I, as parent or legal guardian of this minor child, hereby authorize Lewis Cass Schools to release copies of and information from the above student's education records, as defined by the Family Educational Rights and Privacy Act(''FERPA''), to:
the Indiana State Department of Health's Children and Hoosiers Immunization Registry Program(CHIRP) and all parties who have legal access to CHIRP data as described below.
This authorization is made pursuant to FERPA regulations, 34 CFR Part 99.30, 20 U.S.C. 1232g(b)(1) and 20 U.S.C. 1232g(b)(2)(A).

The following education records and information may be released:
name, date of birth, immunization data as it appears on SESC immunization records, and demographic information (race, guardian's name, and address)
This information is being requested and release is authorized for the following reasons:
The information will be entered on the web based Indiana State Department of Health's CHIRP registry. I understand that the information in the CHIRP registry may be accessed and used by multiple parties authorized by law. The information may be used to verify that my child has received immunizations and to inform. me or my child and other authorized parties of my child's immunization status or that an immunization is due according to immunization schedules .I understand that my child's information will be available to the immunization data registry of another state, a healthcare provider, a local health department, an elementary or secondary school that is attended by the individual, a child care center, and the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning. I also understand that other entities may be added to this list through amendment to Indiana law, I.C. 16-38-5-3.
I understand CHIRP is an online database accessible by physicians, health departments, and schools and others so that these parties can enter and view immunization data. By law, it is confidential and it is accessible to registered users who work for authorized entities. I understand that I have a right to opt out of CHIRP, and that if I choose to do so a form will be provided for me to fill out to have my child removed from the CHIRP database. I understand that (1)
I have the right not to consent to the release of my child's educational records; (2) 1 have the right to receive a copy of my child's education records upon request; and (3) that this consent shall remain in effect until revoked by me, in writing, and delivered to Southeastern School Corporation, but that any such revocation shall not affect disclosures previously made by Southeastern Schools.
By completing the items below, I give permission for Lewis Cass Schools to access my child’s immunization records and share a copy of those records with Little Kings Preschool to be kept in my child’s file. I understand that if I do not agree to this then it is my responsibility to provide Little Kings Preschool with an up to date immunization record for my child.