217-463-7875
FAX 217-466-0012
JANE FURRY RN
DISTRICT 95 NURSE
I am requesting a copy of my immunization record.
My date of birth is: ________________ My year of graduation is: __________________
______ Please send to _____________________________________________________
______ Please give to _____________________________________________________
_____________________________________________________
Signature of person picking up if other than student
(upon receipt)
______________________________________________________
Please print student’s name
______________________________________________________
Signature (Parent, Guardian, or Student if 18 or older)
___________________
Date