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