DOCUMENTATION OF VARICELLA DISEASE

(To be filled out by the parent, guardian, or medical provider of the child/student. Print out and return to school nurse.)


This document is being submitted on behalf of:

_____________________________________________________________
(Name of child/student) (Birth date of child/student)

I ______________________________________ verify that the above listed
(Parent/guardian/medical provider)

child/student had the varicella disease in __________ (year).

________________________________________
(Signature of parent/guardian/medical provider)