Adopted: January 2004
Revised: June 2014
Dear parent/guardian of __________________________________, Date _______________
print student name
In order to be in compliance with state law, your child needs to be current on all required immunizations or provide documentation of exemption prior to the first day of 7th grade during the upcoming school year.
We do not have a record of a:
2nd MMR (Measles, Mumps and Rubella) immunization 2nd HepB (Hepatitis B) immunization
2nd Varicella (Chicken Pox) immunization 3rd HepB (Hepatitis B) immunization
3-dose series of HepB (Hepatitis B) vaccine Polio (IPV, OPV) immunization
Tdap (Tetanus, Diphtheria and Pertussis) or Meningococcal immunization
Td (Tetanus, Diphtheria) booster
as required by state law for your child. If a record of your child receiving this/these immunization(s) or proof of exemption is not received in the school nurse’s office by the first day of school, your child will not be permitted to attend school until the requirements of the law are met.
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There are several ways in which you may comply with this law:
1. Once the immunization indicated above has been given, write the date (month, day, year) of the immunization on the Student Immunization Form located on the reverse of this document, sign where indicated, and return this document to your school nurse; or
2. If your child has received at least one of a series of immunizations and will complete the series within the next eight months, the physician must indicate such and sign the Student Immunization Form located on the reverse of this document, then return the document to your school nurse; or
3. If your child will not receive the immunization due to a medical contraindication or laboratory evidence of immunity, you must give the school nurse a statement signed by a physician (you may use the statement on the reverse of this document), or
4. If your child will not receive the immunization due to conscientiously held beliefs, you must give the school nurse a notarized statement signed by the parent or guardian (you may use the statement on the reverse of this document)
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If you meet any one of the following Minnesota Vaccines for Children (MnVFC) eligibility criteria, you may call Dakota County Public Health (952-891-7999) to receive low-cost vaccinations (There may be no charge for the vaccine for children meeting the criteria listed below):
· You are uninsured;
· You are enrolled in Minnesota Medical Assistance (MA), Minnesota Care (MnCare) or Prepaid Medical Assistance Program (PMAP);
· You are an American Indian or Alaskan Native, or
· You have health insurance that does not cover the cost of the vaccine.
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According to Minnesota Statute 121A.15 (immunization law for school children), your child will not be permitted to attend school if the school nurse has not received one of the above proofs of compliance by the first day of 7th grade.
We appreciate your timely attention to this matter. If you have any questions, please call your school nurse.
Sincerely,
Principal ______________________________ School Nurse______________________________