Immunization Transfer

Sumner County Immunization Transfer Form

Health Dept Immunization Record Transfer

Parent/Guardian/Caregiver Information

Guardian Name

First

Last

Address

City

State/Province

Zip/Postal

County

Phone

Alternate Phone

Child/Student Information

Student First Name

Student MI

Student Last Name

Student DoB

Gender

Ethnicity

Race

School grade entering

Has your child ever had the Chickenpox disease (varicella)?

If yes, please provide the estimated date of illness

Are you relocating from outside of the continental United States?

IF YES, please provide the territory/state/country you are coming from

How would you like to receive your Tennessee Certificate of Immunization?

What is the name of the school?

Please UPLOAD your child’s immunization records. Please note, we MUST be able to clearly read the documents. Blurry or poor quality uploads will not be used.

Maximum upload size: 268.44MB

By providing your digital signature you are agreeing to the following:

I certify that I am the legal guardian or person legally designated to make healthcare decisions on behalf of the above named child and that all information provided is true and accurate to the best of my knowledge. I authorize the Sumner County Health Department to access, update and or create the above named child’s record for official use and release the record in-person, by mail or email.

Legal Guardian Full Legal Name (digital signature)

Sumner County Immunization Transfer Form

Parent/Guardian/Caregiver Information

Child/Student Information

By providing your digital signature you are agreeing to the following:

BZA Meeting Rescheduled