Immunization Form The Village Preschool
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1VILLAGE PRESCHOOL
9 Mountain Avenue
Bayville, NY 11709
(516) 628 - 8655
All students, new entrants, as well as attendees, must meet the immunization requirements set forth
in Section 2164 of the Public Health Law. Written proof of immunization by a certif
ied physician with
said physician's STAMP a xed is required.
Arrangements for immunizations may be made with your family doctor or call the Department of
Health for locations of free clinics.
Child's Name _____________________________________
Date of Bi rth ________________
Diphtheria toxoid: (DPT) Series of 3 or more:
Date:
#1___/___/___
#2___/___/___
#3___/___/___
Boosters
___/___/___
___/___/___
Polio: Sabin (TOPV) Series of 3 or more:
Date:
#1___/___/___
#2___/___/___
#3___/___/___
Boosters
___/___/___
___/___/___
or
Polio: Salk (IPV) Series of 4:
Date:
#1___/___/___ #2___/___/___ #3___/___/___ #4___/___/___
Measles: Live vaccine after age 12 months
___/___/___
Mumps: Live vaccine after age 12 months
___/___/___
Rubella: Live vaccine after age 12 months
___/___/___
or
Serological evidence of rubella antibodies
___/___/___ Results_______
Haemophilus In uenza (type B): (HIB)
___/___/___
Physician's Signature
________________________________Date______________
Physician's STAMP
** This form must be completed, signed and STAMPED by the child's
physician and mai led no later than August 1st
to the above address
.
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