PERU COMMUNITY SCHOOLS
DATE: October 2008
Name: ____________________________
TO: Parents of immunization deficient children
RE: Chicken Pox Vaccine
The Indiana Department of Health now requires all children attending school in Indiana
(Grades K-12) to have the chicken pox (Varicella) vaccine OR have documentation from
the parent that the child has had the chicken pox disease on file with the school.
In checking school records, your child was found to be in need of the chicken pox
(Varicella) vaccine, or there was no parent report stating your child has had the
chicken pox disease.
Please check the appropriate statement for your child and return this form to your child’s
School Nurse.
1. _____ My child has had the chicken pox disease.
Month and Year_______________________
2. _____ My child has had the chicken pox (Varicella) vaccine.
You must submit documentation of
the updated shot record to your child’s School Nurse.
3. _____ My child has never had chicken pox disease or the chicken pox vaccine.
Date of appointment to receive chicken pox (Varicella)
vaccine_________________
*** When complete, please turn in a copy of the updated immunization
record to your School Nurse.
Questions about this notice should be directed to your child’s School Nurse.
Chicken pox (Varicella) vaccine may be received from your private physician or the
Miami County Health Department (Phone # 472-3901 Ext # 215).
Parent/Guardian Signature_________________________________________________
Date: _______________________________________