What information does the Pediatric Immunization Registration Form ask for?

It asks for the child's and parent or guardian's contact and demographic details, family income and household size, and answers to health screening questions. Office-use fields include insurance or payment category, race, and ethnicity.

Who completes this form?

A parent or guardian can provide the child's information and answer the screening questions. The form also has sections marked for office use.

Do I need a notary for the Pediatric Immunization Registration Form?

No. This form is signed and dated without a notary, and it contains no notarized or sworn attachment or related step.

How do I submit the Pediatric Immunization Registration Form?

The form does not give submission instructions. Submit it to the county department named on the form and check the county website for current contact details.

Lenawee County, MI · Lenawee County

No notary required

Pediatric Immunization Registration Form

Parents or guardians use this Lenawee County Health Department form to register a child and provide information for pediatric immunization screening.

At a glance

Issued by: City of Lenawee County · Lenawee County, Lenawee County, Michigan
Notarization: Not required: file this form without a notary.
Official source: lenawee.mi.us
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

This form gathers a child's and parent or guardian's contact details, demographic information, and answers to health screening questions related to immunizations. It also includes office-use fields for insurance or payment category, race, and ethnicity. The form is titled as a pediatric immunization pre-registration form, but it does not state when registration is required or give submission instructions.

Who needs it

A parent or guardian registering a child for pediatric immunization services through the Lenawee County Health Department can complete this form.

How to submit it

Submit it to the county department named on the form; check the county website for current contact details.

About notarization

This form is signed and dated without a notary; it contains no notarized or sworn attachment or related step.

How to submit this form

1
Download the Form
Download the Pediatric Immunization Registration Form.
2
Complete the Child's Information
Enter the child's and parent or guardian's contact and demographic information.
3
Answer Screening Questions
Answer the listed questions about the child's health and vaccination history.
4
Submit to the County
Submit the completed form to the county department named on it; check the county website for current contact details.

Frequently asked questions

What information does the Pediatric Immunization Registration Form ask for?: It asks for the child's and parent or guardian's contact and demographic details, family income and household size, and answers to health screening questions. Office-use fields include insurance or payment category, race, and ethnicity.
Who completes this form?: A parent or guardian can provide the child's information and answer the screening questions. The form also has sections marked for office use.
Do I need a notary for the Pediatric Immunization Registration Form?: No. This form is signed and dated without a notary, and it contains no notarized or sworn attachment or related step.
How do I submit the Pediatric Immunization Registration Form?: The form does not give submission instructions. Submit it to the county department named on the form and check the county website for current contact details.

Need something notarized?

This Pediatric Immunization Registration Form doesn’t need a notary, but Michigan residents can notarize other documents online with a commissioned online notary.