Clintondale Community Schools

Consent for Disclosure of Personally Identifiable Information and Immunization Information to Local and State Health Departments

Immunizations are an important part of keeping our children healthy. Schools and State and Local health departments must monitor immunization level stoen sure that all communitiesare protected from potentially life-threatening diseases and, if necessary, respond promptly to an emerging public health threat. It is important that disease threats be minimized through the monitoring of students beingimmunized.

Sharing immunization and personally identifiable information including the student’s name, Date of Birth, gender, and address with local and state health departments will help to keep your child safe from vaccine preventable diseases. The Family Educational Rights and Privacy Act(FERPA), 20U.S.C.§1232g, requires written parental consent before personally identifiable information and immunization information from your child’s education records is disclosed to the health department. If your child is 18 or over, he or she is an “eligible student” and must provide consent for disclosures ofinformation from his or her education records.

You may withdraw your consent to share this information in writing at any time.

I authorize .................Clintoldale Community School............. to release my child’simmunization recordand personally identifiable information to the Michigan Department of Health and Human Services and Local Health Department. I understand this information will be used to improve the quality and timeliness of immunization services and to help schools comply with Michigan Law. This includes any immunization information and limited personally identifiable information from theschool.
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