MARLBORO TOWNSHIP BOARD OF EDUCATION

1980 TOWNSHIP DRIVE

MARLBORO, NEW JERSEY 07746-2298
HEALTH IMMUNIZATION REQUIREMENTS FOR 6TH GRADE STUDENTS/11 YEARS OLD
***STUDENTS WHO ARE 11 YEARS OLD WHEN SCHOOL COMMENCES IN SEPTEMBER MUST PROVIDE
DOCUMENTATION OF THESE IMMUNIZATIONS ON THE FIRST DAY OF SCHOOL.***

Students Name_________________________________________ Birth Date ____________________

Tdap__________________________________ Menactra_____________________________________
Physicians Signature ____________________________________________ Date_________________
The NJ Department of Health and Senior Services has revised the administrative code (NJAC 8:57-4) to
reflect immunizations before entry into any organized school environment. This requirement took effect
on September 1, 2008.
Please contact your childs health provider. Return this form completed and signed by your childs
physician.
Thank you for assisting us in the completion of this important immunization documentation.

If your child is not yet age eligible (age 11), you must submit a doctors note with a future
appointment date. Please remember to supply this completed form to the school nurses
office on/after your childs scheduled appointment.

rev. 1/10/13