Educational institutions and daycare/preschool facilities require students to show proof of immunization against certain preventable communicable illnesses. The State of Tennessee currently provides immunization records on an official certificate issued by local health departments or by primary care providers who participate in the online immunization information system. All new immunization records must be MANUALLY TRANSCRIBED by department staff. Please allow 1-2 business days for processing. Submissions received after 4:00pm will be processed the next business day.

Parent/Guardian/Caregiver Information:

Guardian First Name: *

Guardian Last Name:*

Street Address:*

Apt./Lot#:

City:*

State:*

Zip code:*

County:*

Cheatham Davidson Dickson Hickman Marshall Maury Robertson Rutherford Sumner Williamson Wilson Other TN county Out of state

Cell phone:*

Home/Alternate Phone:

Email address:*

CHILD/STUDENT INFORMATION:

Student first name:*

Student middle initial:

Student last name:*

Student date of birth:
XX/XX/XXXX*

Gender:*

Male Female

Ethnicity:*

Not hispanic Hispanic

Race:*

White Black Asian American indian Hawaiian/pacific islander Multiracial Other

School grade entering:*

Daycare/Preschool Headstart Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th College

Has your child ever had the Chickenpox disease (varicella)?*

Yes No

IF YES, please provide the estimated date of illness:

Are you relocating from outside of the continental United States?*

Yes No

IF YES, please provide the territory/state/country you are coming from:

How would you like to receive your Tennessee Certificate of Immunization?
*We do not fax certificates to schools or guardians.*

WALK-IN: Please call and I will pick up the certificate US MAIL: Please mail the certificate to the address listed above

Please UPLOAD your child's immunization records in PDF format. Please note, we MUST be able to clearly read the documents. Blurry or poor quality uploads will not be used.*

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

By providing your digital signature you are agreeing to the following:
I certify that I am the legal guardian or person legally designated to make healthcare decisions on behalf of the above named child and that all information provided is true and accurate to the best of my knowledge. I authorize the Williamson County Health Department to access, update and or create the above named child's record for official use and release the record in-person, by mail or email.

Legal Guardian Full Legal Name (digital signature)*