Guardian First Name
* required

Guardian Last Name
* required

Street Address
* required

Apt./Lot #


City
* required

State
* required

Zip Code
* required

County
* required

Cell Phone
* required

Home/Alternate Phone


Email Address:
* required

Student First Name
* required

Student Middle Initial


Student Last Name
* required

Student Date of Birth
* required

Gender
* required

Ethnicity
* required

Race
* required

School Grade Entering
* required

Has your child ever had the Chickenpox disease (varicella)?
* required

If YES, please provide the estimated date of illness


Are you relocating from outside of the continental United States?
* required

If YES, please provide the territory/state/country you are coming from


How would you like receive your Tennessee Certificate of Immunization?


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.
* required

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.
* required

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)
* required