Tip for State-specific

Keep a personal copy of all immunization records — they are difficult to reconstruct if lost

Tip for State-specific

Check your state's immunization registry for a complete, official record

Tip for State-specific

Some states allow a provisional enrollment period while catching up on vaccines

Maternal & PediatriceasyDoctor signature required

Immunization Record / Certificate of Immunization

State-specific · State Departments of Health

Official record of required childhood vaccinations for school enrollment. Exemption forms (medical, religious, philosophical) vary by state.

Form Details

Total fields: 30
Auto-fillable: 25 (83%)
Time without BeneFill: 15 minutes
Time with BeneFill: 4 minutes
Time saved: 11 minutes
Filled by: doctor
Frequency: as needed
State-specific: Yes — form may vary by state

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Where to Submit This Form

🏢

Submit to school, childcare, or healthcare provider

Provide the official record from your child's pediatrician or state immunization registry.

🌐

Access through your state immunization information system (IIS)

https://www.cdc.gov/vaccines/programs/iis/contacts-locate-records.html

Many states offer online portals where parents can view and print official immunization records.

Required Attachments

📎 Official immunization record from the healthcare provider or state registry
📎 Medical exemption form signed by a physician (if applicable)
📎 Religious or philosophical exemption form (if allowed by your state)

Processing Time

Immediate upon submission. Schools typically verify records within 1-2 weeks of enrollment.

What Happens Next

The school or childcare facility will confirm compliance or notify you of any missing vaccinations. You may have a grace period to catch up on missing doses.

Tips for This Form

✓ Keep a personal copy of all immunization records — they are difficult to reconstruct if lost
✓ Check your state's immunization registry for a complete, official record
✓ Some states allow a provisional enrollment period while catching up on vaccines
✓ Required vaccines vary by state — check your state health department website

More Maternal & Pediatric Forms

WIC Application

State-specific · USDA Food and Nutrition Service (state-administered)

Application for WIC nutrition assistance providing education, breastfeeding support, and benefits for healthy foods. Requires proof of identity, address, income (or Medicaid/SNAP/TANF participation), and a health screening.

WIC Medical Documentation / Nutrition Risk Form

State-specific · State WIC agencies

Medical documentation of nutrition risk factors qualifying an individual for WIC, such as anemia, underweight, or high-risk pregnancy.

CHIP Application

State-specific / Healthcare.gov · State CHIP agencies

Application for Children's Health Insurance Program for families with income too high for Medicaid but too low for private coverage. Uses MAGI-based financial eligibility. Children must be uninsured.

School Entrance Health Form

State-specific (e.g., VA MCH213G) · State Departments of Health/Education

Required for school entry. Includes immunization records, health history, physical examination, and developmental screening. Must be completed no earlier than one year before school entry.

Medication Administration Authorization (School)

District-specific · School districts

Authorization for school nurse or designee to administer prescribed medication during school hours.

Section 504 Plan (Medical)

District-specific · School districts

Accommodation plan for students with health conditions (diabetes, allergies, asthma, ADHD) that impact school participation. Includes a medical management plan and emergency action plan.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Departments of Health or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.