Request for Official State of Michigan Immunization Record Please print except where indicated Name on Requested Record: Child’s Birth Date: Last Name Month Date: First Name Day Middle Name Year Requestor’s Name: Requestor’s Relationship to Child: Address Old Current Address: Have you recently moved? If so, please provide both old and new addresses. If not, provide current address. Street City Zip Code County New Address: Telephone Old Current Telephone Number: NOTE: Street City State Zip Code Has your telephone number recently changed? If so, please provide both the old and new number. Area Code/Number Area Code/Telephone Number New Number: If the requestor is a social services agency, please provide a formal request with parental/legal guardian’s signature and a photocopy of their state-issued I.D., along with a photocopy of requestor’s state-issued I.D. Requestor’s Signature Date Instructions for completing this request Please complete the form by printing all requested information as completely as possible. Provide any additional information requested. Please send a photocopy of a state-issued I.D. in the name of the requestor. Mail this request to: Michigan Dept of Community Health-Immunization Program, 3423 N. Martin Luther King Blvd., P.O. Box 30195, Lansing, Michigan 48909. Please allow 7 business days for processing. For Office Use Only American LegalNet, Inc. www.FormsWorkflow.com