# JLCB-E3 - MSAD 35 Vaccination Catch Up Plan
**JLCB-E3 - MSAD 35 Vaccination Catch Up Plan**
| Vaccine
| Date
| Date
| Date
| Date
| Date
|
| Dtap
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| Polio
|
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| MMR
|
|
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| Varicella
|
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|
|
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| Tdap
|
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| Meningococcal
|
|
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This student is following the above schedule to get caught up on Maine Immunization requirements for school attendance. Please consult with your PCP, have this document signed by him or her and return a copy of it to your school nurse. Please have it updated at each visit and send documentation of immunization to your child’s school nurse.
Student: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Parent: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Health Care Provider (MD, DO, NP or PA):
Print: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Signed: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Cross Reference: JLCB and JLCB-R
Policy Adopted: March 16, 2022