Immunization Disclosure

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Immunizations are an important part of keeping our children healthy. Schools, along with State and local health departments, must monitor immunization levels to be ensure that all communities are protected from potentially life-threatening diseases and, if necessary, respond promptly to an emerging public health threat. It is important these disease threats be minimized through the monitoring of students being immunized.

Sharing immunization and personally identifiable information, including the student's name, date of birth, gender and address with local and state health departments will help keep your child safe from vaccine-preventable diseases. The Family Educational Rights and Privacy Act (FERPA) 20 U.S.C. s 1232g, requires written parental consent before personally identifiable information from your child's education records is disclosed to the health department.

You many withdraw your consent to share this information at any time by providing written notice.

Email *

Child's Name *

Child's Date of Birth *

YYYY

Name of Parent *

I authorize St. John's School to release my child's immunization record to the Michigan Department of Health and Human Services and Local Health Department. I understand this information will used to improve the quality and timeliness of immunization services and to help schools comply with Michigan law. This includes any immunization information and limited personally identifiable information from the school *

I Agree

I Disagree

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