MADISON SCHOOL DISTRICT

359 Woodland Road • Madison, NJ 07940 • (973) 593-3100

Dear Fifth Grade Parent,

Student’s Name______Birthdate:______

This letter is to inform you of the immunization requirements for students, who will be attending Grade Six in September. If your child’s birthday is after September 1, 2009, please schedule an appointment with your healthcare provider on or soon after their birthday to receive these immunizations. He/she will need to receive these immunizations within a week after their 11th birthday.

The two required immunizations are for the following diseases:

1. Pertussis, commonly known as whooping cough, has been occurring more frequently in adolescents and adults when immunity wanes. The infection produces a severe cough which can last for many weeks.

2. Meningococcal disease, commonly known as meningitis, is a potentially fatal bacterial infection that can strike teenagers and college students. The disease can come on quickly and may cause death or permanent disability within hours of the first symptoms; although rare the disease may be prevented through vaccination.

The new regulations approved by the State of New Jersey, Department of Health and Senior Services, Immunization Program are:

1. N.J.A.C. 8:57-4.10 requires children born on or after January 1, 1997 and enrolled in Grade Six or transferring into a New Jersey school (any grade) from another state or country to receive one dose of the tetanus, diptheria, acellular pertussis (Tdap) vaccine.

2. N.J.A.C. 8:57-4.20 requires children born on or after January 1, 1997 and enrolled in Grade Six or transferring into a New Jersey school (any grade) from another state or country to receive one dose of meningococcal (meningitis) vaccine.

Therefore in order for your child to attend Grade 6 at the Junior School in September, he/she will need the following immunizations as indicated below. Proof of these immunizations needs to be provided to the school nurse at your child’s school as soon as your child receives them. Please have the physician complete this form when your child is vaccinated and return it to your school nurse or provide documentation on the physician’s prescription pad, or vaccine record.

_____1.Tetanus, diphtheria, acellular pertussis (Tdap) vaccine Date Received______

_____2.Meningococcal (Menactra) vaccine Date Received______

Date ______Physician’s Stamp or Signature: ______