Utah Statewide Immunization Information System (USIIS) Agreement Form

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Only a person who is legally allowed to enroll this student in school is allowed to complete this form: a birth or adoptive parent, OR an adult with a current notarized POA with decision-making authority for this student, OR an adult awarded legal guardianship of this student through the court, OR a this student's foster/proctor parent, OR this student's DFCS case worker may complete this form for this student.

In Providence Hall Charter School, all programs and services are open to all persons regardless of their race, color, national origin, sex, age, and disabilities.

Student First Name(s) as on Birth Certificate *

Student Last Name(s) as on Birth Certificate *

Student Date of Birth (mm/dd/yyyy) *

YYYY

The Utah Department of Health has an online registry that records immunizations called USIIS. This information is recorded only by providers in the state of Utah. Our school nurses have access to this information, in the case that the record needs to be updated or the nurse finds a discrepancy in the report versus what has been provided to them. Do you give PH nurses permission to update the state record in USIIS?
*

Agreements & Verifications *

I verify that I have read, understand, and agree to this statement.

My USIIS response in this form will be applied for the duration of my student's enrollment with PHCS and if I wish to alter my decision, I am required to contact the appropriate school nurse.

I confirm that I legally allowed to complete this form for this student (see the statement above under the title of this form).

I am signing this form electronically and my electronic signature is the legal equivalent of my manual signature on this form.

I verify that I have read, understand, and agree to this statement.

My USIIS response in this form will be applied for the duration of my student's enrollment with PHCS and if I wish to alter my decision, I am required to contact the appropriate school nurse.

I confirm that I legally allowed to complete this form for this student (see the statement above under the title of this form).

I am signing this form electronically and my electronic signature is the legal equivalent of my manual signature on this form.

Type in First & Last Name of Parent/Guardian who completed this form as Signature *

Today's DATE (mm/dd/yyyy) *

YYYY

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