*** IMPORTANT *** Read before you submit.
** Parent/Guardian signature here indicates the above information is true in regards to health history, self-administration of non-prescription pain meds, and immunization records, as well as allowing my child’s school to share my child’s immunization documentation with Minnesota’s immunization information system.
Consent to share immunization information: This school is asking for permission
to share your child’s immunization record with Minnesota’s immunization informationsystem. Giving your permission will:
• Provide easier access for you and your school to check immunization records, such as at school entry each year.
• Support your school in helping to protect students by knowing who may be
vulnerable to disease based on their immunization record. This can be important
during a disease outbreak.
Under Minnesota law, all the information you provide is private and can only be released to those authorized to receive it. Signing this section of the form is optional. If you choose not to sign, it will not affect the health or educational services your child receives.
Please contact ALC at 218-336-8756 if you cannot sign for all of the above and we will provide a paper copy so you can sign only the portions you agree with.
Please visit ISD709 Health Services for more information (LEFT CLICK to open in a new page so you don't lose your work above!).
HS-49e (Rev. 4/16) Item #35-15-000885