Request for Immunization Records

This request authorizes Grapevine-Colleyville ISD Health Services to provide a copy of immunization records. Any immunization records on file will be sent in the manner selected below. Former students who are 18 years or older must request their own immunization records. If you are requesting records during the school year for a current student, please contact their home campus.

1. Student's First Name While Attending School *

Your answer

2. Student's Middle Name While Attending School *

Your answer

3. Student's Last Name While Attending School *

Your answer

4. Name of Last GCISD School Attended *

5. Date of Birth *

YYYY

6. Phone *

Your answer

7. Email

Your answer

8. Fax

Your answer

9. Please select the method you wish the records to be provided: *

Fax

Required

10. Typing your name below represents your digital signature which verifies that you have reviewed the above and that you certify that the information provided is true and accurate. I authorize GCISD Health Services to release the requested immunization records to the person named on this form. In compliance with the Family Education Rights and Privacy Act of 1974, I understand that without my signature on this form, my request cannot be processed. (Student Signature if over 18 years old.) *

Your answer

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