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SPS Registration: Certificate of Immunization Status (CIS)
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* Indicates required question
Email
*
Your email
Student Last Name
*
Your answer
Student First Name
*
Your answer
Student Middle Name
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
I give permission to my child’s school/child care to add immunization information into the Immunization Information System to help the school maintain my child’s record.
*
Yes
No
Conditional Status Only: I acknowledge that my child is entering school/child care in conditional status. For my child to remain in school, I must provide required documentation of immunization by established deadlines.
*
Yes
No
Parent/Guardian Signature (please type first & last name)
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Your answer
Date
*
MM
/
DD
/
YYYY
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