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**

2.	Students Middle Name While Attending School**

3.	Students Last Name While Attending School**

4.	Name of Last Wylie ISD School Attended**
	--Please Select--Akin ElementaryBirmingham ElementaryBush ElementaryCox ElementaryDodd ElementaryGroves ElementaryHartman ElementarySmith ElementaryTibbals ElementaryWatkins ElementaryWhitt ElementaryDavis IntermediateDraper IntermediateHarrison IntermediateBurnett Junior HighCooper Junior HighMcMillan Junior HighWylie High SchoolWylie East High SchoolAchieve 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:**
	Please select the method you wish the records to be provided:** 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.)*