JLCB-E3 - MSAD 35 Vaccination Catch Up Plan

JLCB-E3 - MSAD 35 Vaccination Catch Up Plan   
 
 Vaccine 
 
 
 Date 
 
 
 Date 
 
 
 Date 
 
 
 Date 
 
 
 Date 
 
 
 Dtap 
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
 Polio 
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
 MMR 
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
 Varicella 
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
 Tdap 
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
 Meningococcal 
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 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