NOTICE OF IMMUNIZATIONS NEEDED
Dear Parent/Guardian of: ___________________________________________________
Our records show that your child needs the following immunization(s) (shots) to meet the
requirements of the California School Immunization Law, Health and Safety Code Sections
120325-120375:
YOU NEED TO DO ONE OR MORE OF THE FOLLOWING IMMEDIATELY:
1. If your child has already received all of these immunizations marked above, bring us the immunization
record so that we can update our files. Your child’s record must include a date for the immunizations
checked above and the doctor’s/clinic’s name.
2. If your child has not already received all of the immunizations marked above, bring this form along with
your child’s immunization record to your doctor or local health department to get the immunization(s)
marked above. Bring us your child’s updated immunization record after every immunization visit until all
of the required immunizations have been received.
3. If any of these immunizations were not given to your child because of medical reasons, please bring us a
medical exemption form issued using the CAIR-Medical Exemption website by your child’s doctor (MD or
DO licensed in California).
According to state law, we cannot allow your child to attend unless we receive
evidence that the above requirements are met by this date:
For more information on pre-kindergarten (child care or preschool) and school immunization requirements,
visit www.shotsforschool.org.
If you have any questions or require additional information, please call .
Sincerely,
VACCINE MISSING DOSE(S) MARKED BELOW:
Polio
#1 #2 #3 #4
DTaP (Tdap or Td if age 7 years or older.) #1 #2 #3 #4 #5
MMR #1 #2
Hib (child care/preschool only) #1 #2 #3 #4
Hepatitis B #1 #2 #3
Varicella (chickenpox) #1 #2
Tdap (for 7th–12th grade) #1
IMM-1140 (2-21)
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