Documentation of Varicella Disease

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)