East Syracuse Minoa Central School District

Information Needed for Immunization Record Request

• First name, middle name or initial, current last name, maiden name
• Your address, including street, city, state and zip code
• Date of birth
• Year of graduation or date of withdrawal from school
• A phone number where you may be reached, including area code
• Name, email or address of the college/university or employer & company requesting a copy of your immunization record