Request for Immunization Records
This request authorizes Wylie ISD Health Services to provide a copy of immunization records. Any immunization records on file will be sent in the manner selected below. Former students who are 18 years or older must request their own immunization records. If you are requesting records during the school year for a current student, please contact their home campus.
1.
Students First Name While Attending School*
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2.
Students Middle Name While Attending School*
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3.
Students Last Name While Attending School*
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4.
Name of Last Wylie ISD School Attended*
*
--Please Select--
Akin Elementary
Birmingham Elementary
Bush Elementary
Cox Elementary
Dodd Elementary
Groves Elementary
Hartman Elementary
Smith Elementary
Tibbals Elementary
Watkins Elementary
Whitt Elementary
Davis Intermediate
Draper Intermediate
Harrison Intermediate
Burnett Junior High
Cooper Junior High
McMillan Junior High
Wylie High School
Wylie East High School
Achieve Academy
5.
Date of Birth*
*
mm/dd/yyyy
Delivery Method Information
6.
Phone Number*
*
7.
Email Address
8.
Fax Number
9.
Please select the method you wish the records to be provided:*
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Please select the method you wish the records to be provided:*
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Email
Fax
10.
Typing your name below represents your digital signature which verifies that you have reviewed the above and that you certify that the information provided is true and accurate. I authorize Wylie ISD Health Services to release the requested immunization records to the person named on this form. In compliance with the Family Education Rights and Privacy Act of 1974, I understand that without my signature on this form , my request cannot be processed. (Student Signature if over 18 years.)
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