Rutherford County Health Department
Guardian First Name
Guardian Last Name
Student First Name
Student Middle Initial
Student Last Name
Student Date of Birth
School Grade Entering
Has your child ever had the Chickenpox disease (varicella)?
If YES, please provide the estimated date of illness
Are you relocating from outside of the continental United States?
If YES, please provide the territory/state/country you are coming from
Please UPLOAD your child's immunization records in PDF, JPEG, or PNG format. Please note, we MUST be able to clearly read the documents. Blurry or poor quality uploads will not be used.
Please UPLOAD your child's physical examination records in PDF, JPEG, or PNG format. Please note, we MUST be able to clearly read the documents. Blurry or poor quality uploads will not be used.
By providing your digital signature you are agreeing to the following:
I certify that I am the legal guardian or person legally designated to make healthcare decisions on behalf of the above named child and that all information provided is true and accurate to the best of my knowledge. I authorize the Rutherford County Health Department to access, update and or create the above named child's record for official use and release the record in-person, by mail or email.
Legal Guardian Full Legal Name (digital signature)