Request for Immunization Records

	This request authorizes Rockwall 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 Rockwall ISD School Attended*
	--Please Select--Rockwall High SchoolRockwall-Heath High SchoolQuest AcademyCain Middle SchoolUtley Middle SchoolWilliams Middle SchoolAmanda Rochell ElemenatyAmy-Parks Heath ElementaryBillie Stevenson ElementaryCelia Hays ElementaryDoris Cullins-Lake Pointe ElementaryDorothy Smith Pullen ElementaryDorris A. Jones ElementaryGrace Hartman ElementaryHoward Dobbs ElementaryNebbie Williams ElementaryOuida Springer ElementarySharon Shannon ElementaryVirginia Reinhardt ElementaryLinda Lyon ElementarySherry & Paul Hamm ElementaryLupe Garcia Elementary

5.	Date of Birth*
	mm/dd/yyyy

6.	Phone*

7.	Email

8.	Fax

9.	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 Rockwall 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.)