School Immunization Release
I authorize the school marked below to release my child's immunization records to Minnesota Immunization Information Connection (MIIC). I understand this information can only be used to improve the quality and timeliness of immunization services and to help schools enforce the School Immunization Law. This includes any immunization information the school currently has plus any it may obtain during the 2019-2020 school year.

Please contact Brown County Public Health at 507-233-6820/888-359-2809 with any questions.

Student's First Name *
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Student's Last Name *
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Student's Birth Date *
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Grade Level *
School Name *
Parent's Signature
I have agreed to submit this form by electronic means. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. *By typing my name below, I am electronically signing my form.
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