JLCB-E2 - Immunization Signature Form for Enrollment

JLCB-E2 - Immunization Signature Form for Enrollment  
 I.  My child is fully immunized and proof has been submitted with this form. 
 PARENT/GUARDIAN   ________________________   DATE _____ 
 RN SIGNATURE: ____________________________   DATE _____ 
 
 II. I understand that within 90 days of enrollment, my child needs to show proof of immunization against the diseases listed above. Students transferring from one school system to another within Maine, have 21 days to demonstrate proof of immunity. 
 PARENT/GUARDIAN ___________________________ DATE ______ 
 RN SIGNATURE:   ______________________________ DATE _____ 
 
 III. I have received a copy of the MSAD 35 Vaccination Catch Up Plan 
 PARENT/GUARDIAN _________________________________ DATE ______ 
 RN SIGNATURE:   ___________________________________ DATE ______ 
 
 IV . I have received a copy of the ME AAP Medical Exemption Form 
 PARENT/GUARDIAN _______________________________ DATE ______ 
 RN SIGNATURE:   _________________________________ DATE _____ 
 
 V. My child had both an IEP and religious or philosophical exemptions in place prior to Sept 2021 and I have received a copy of the Immunization Exemption Form 
 PARENT/GUARDIAN __________________________ DATE ______ 
 RN SIGNATURE:   _____________________________ DATE _____ 
 
 Cross Reference: JLCB and JLCB-R 
 Policy Adopted: March 16, 2022