ST. MARY S NURSERY SCHOOL
P.O. BOX 782 — 165 PONQUOGUE AVE.
HAMPTON BAYS, NY 11946
728-0567
According to amendments to Public Health Law Article 21, Section 2164,
school authorities cannot permit children to enter or attend school without a
certificate of immunization.
Please have the following certificate of immunization completed by your
physician, and return it to St. Mary s Nursery School before your child starts
his/her first day.
CERTIFICATE OF IMMUNIZATION
Name of child________________________Date of Birth_______________
Address_____________________________Phone___________________
Has had immunization against: List dates:
Tetramune:
Acel DPT:
DT:
DPT:
OPV:
IPV:
HIB:
MMR:
Hep B:
Varivax:
Tine Test:
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Check if History and Describe:
Asthma or Allergies:
Ear Conditions:
Operations:
Serious Injuries:
Eye Conditions:
Does your child wear glasses?_____
Are the glasses made of safety lenses?_____