Consent for Disclosure of Immunization Information to Local and State Health Departments

(For students entering K, 7th grade, or transferring in from another school district.)

Immunizations are an important part of keeping our children healthy. Schools and State Local health departments must monitor immunization levels to ensure that all communities are protected from potentially life-threatening diseases, and, if necessary, respond promptly to an emerging health threat. It is important that 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 to keep your child safe from vaccine preventable diseases. The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g, requires written parental consent before personally identifiable information from your child's education records is disclosed to the health department. If your child is 18 or over, he or she is an "eligible student" and must provide consent for disclosures of information from his or her educational records.

You may withdraw your consent to share this information in writing at any time.

I authorize Pewamo-Westphalia Community Schools 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 be 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.