Varicella (chickenpox) Immunity Statement

Please complete this form regarding your child's immunity information.

• Student Name *

  (Last, First)
• Date of Birth *
• School *

  Which school does your child currently attend?
• Method Immunity was Acquired *
  Varicella Vaccine

  Varicella Lab

  Varicella Disease

  Check one of the following boxes and provide corresponding information below.
• Date of Varicella Vaccine
• Evidence Date of Varicella Lab
• Age of child when he/she had chickenpox
• Accuracy Statement *
  I attest that the information within this form is true.
• Name of Parent/Guardian *
• Date Form was Completed *