School Nurse: Mrs.
Cindy Halley
Phone: (618)
842-2649 ext. 233
Fax: (618) 842-5187
REQUEST FOR
IMMUNIZATION RECORDS
How can
immunization records be obtained?
By
mail, fax or stopping by in person.
What is the mailing
address?
Attn:
School Nurse
300
W. King
Today’s
Date:_______________________________________
Your
last name when in school (Maiden):______________________________________
Your
current last name:____________________________________________________
First
Name:______________________________________________________________
Date
of Birth:______________________
Year
Graduated/Last year you attended:_______________________
Mail
to:__________________________________________
________________________________________________
________________________________________________
________________________________________________
Fax
to:___________________________________________
Signature:_______________________________________________________________________(required)