DEWITT SCHOOL DISTRICT

DeWitt, Arkansas

School Immunization Clinic

In compliance with the Family Education Right to Privacy Act (FERPA) (20 U.S.C. § 1232g;34 CFR Part 99).

I, _______________________________________________________, (parent/guardian name) give permission for my child, ________________________________________, (first and last name) to participate in the School Immunization Clinic.  I understand that the appropriate Arkansas Department of Health consent forms will be provided for my consideration prior to the clinic.

Parent/Guardian Signature ______________________________________________________

Date Signed _______________________