2023-2024 Immunization Release Form

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2023-2024 Immunization Release Form

2023-2024 Immunization Record Release Form

This form “OSSIS – Authorization to Use or Share Protected Health Information to School or Day Care” will be used by the school in order to more efficiently collect required immunization records for each student. With consent, school personnel can access your child’s immunization records speeding up the enrollment process while eliminating the need for you to submit a copy. School personnel will no longer need to wait on receiving your child’s school records from the previous school district to collect this information.

Oklahoma State Immunization Information System Release Form

Type the name and birth date for each student that will be attending E-School (Ex. Jack Smith – 10/01/2008).(Required)

I understand that by voluntarily signing this authorization:

Unless revoked or otherwise indicated, this authorization's automatic expiration date will be one year from the date of my signature or upon the occurrence of the following event (e.g., child no longer enrolled in school/day care center):

Name of Legal Parent/Guardian. I acknowledge that the I am the legal parent/guardian of the student(s) listed above. Typing the name will act as the Legal Parent/Guardian Signature.(Required)

First Last

Description of Legal Representative's Authority(Required)

Legal Parent

Legal Guardian

Date of Signature(Required)

2023-2024 Immunization Release Form

2023-2024 Immunization Record Release Form

Oklahoma State Immunization Information System Release Form

I understand that by voluntarily signing this authorization:

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