Immunization Request Form
Name
*
First Name
Last Name
Student ID
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Year began school at TLU
Email (Please provide a current email address)
*
example@example.com
Immunization Record requested and why
*
Can we email you a copy of your immunization records?
Yes
No (If no, you will need to come pick up your records from TLU.)
Signature
Save
Submit
Submit
Should be Empty: