Immunization Record/Statement of Exemption - Connections Academy 2026

1. Click ‘Get Form’ to open the Immunization Record/Statement of Exemption in the editor.
2. Begin by entering the student's name and date of birth at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill out the Student Information section, including gender, current grade, home phone, mobile phone, street address, city, state, and ZIP code.
4. In the Known allergies or reactions to vaccines field, provide any relevant medical history that may affect immunization.
5. The Immunizations section must be completed by a healthcare provider. Ensure they indicate the dates for each vaccine administered and sign where required.
6. If requesting an exemption, complete the appropriate statement and ensure it is signed by both the healthcare provider and parent/legal guardian.
7. Review all entries for completeness and accuracy before submitting. Refer to the Document Cover Page for submission instructions.

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