I, the parent/guardian of {studentsName}, DOB {studentsDate} give Goshen Community Schools permission to release the following information to the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP): All immunization records and personal identifying information from the CHIRP data base. For example, but not limited to: name, address, phone number, birth date, school name.
I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me or my child of my child’s immunization status or that an immunization is due according to recommended immunization schedules.
I understand that my child’s information may be available to the immunization data
registry of another state, a healthcare provider or a provider’s designee, a local health department, an elementary or secondary school, a childcare center, the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning, a licensed child placing agency, and a college or university. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3.
By clicking next I hereby consent to the release of such information.
*Signature for this and all forms will be done on the last page of registration.