Health Department

IMMUNIZATION CONSENT FORM

In compliance with the requirements of the State of Connecticut, regarding immunization for admission to private and public schools; I give my permission/consent for the school physician to complete any and all immunizations, and the physical examinations that are and may be required by the State of Connecticut for my daughter __________________________________.

Signed:  __________________________________

Date:     __________________________________  

Thank you for your cooperation.

Academy of the Holy Family

Health Department