Immunization Form- Requires Health Care Provider Signature

Health Care Summary- Requires Health Care Provider Signature
This form must be signed with a Doctor's signature on Page 2. Below are the steps that need to be completed before this form can be submitted to Little Stars.
- Step 1- Fill in the required information on the form
- Step 2- Click "Preview PDF" to ensure information is accurate
- Step 3- Click "Generate Form". A copy of the form will be sent to the email address entered.
- Step 4- Print the form
- Step 5- Sign and date the form
- Step 6- Upload the completed form by visiting the secure upload here https://oriforms.jotform.com/231338605709963?jumpToPage=8
Important Notes:
- Medical and non-medical exemptions require notarization (Section 1, A and B)
- History of chickenpox(varicella) disease require a signature from a health care provider (Section 2)
Child Name*

First NameLast Name
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Parent/Guardian Email*
example@example.com
I have clicked "Preview PDF" and reviewed my form for accuracy*

YesNo
Please verify that you are human*
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