I give Blackhawk Christian School permission to release the following information concerning my child to the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP):
- Student Name
- Date of Birth
- Address
- Phone Number
- Immunization Information
- BCS Grade Level
- Parent/Guardian Names
- Ethnicity
I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me of my child’s immunization status or that an immunization is due according to recommended immunization schedules.
I understand that my child’s information may be available to the immunization data registry of another state, a health care provider or a provider’s designee, a local health department, an elementary or secondary school, a child care center, the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning, a licensed child placing agency, and a college or university. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3.
