School/Early Childhood Program Order Form

Date: Organization:
Name: Address:
City: State:   Zip:
Phone: Fax:

Please order the number of packages needed: English Spanish
Record Cards Pink USIR (cards may be ordered individually) Due to increased
demand, your USIR order will be adjusted as necessary. (250)
Schedule Cards Adolescent (100)
Childhood (100)
Childhood 8.5 x 11 (50)
Posters Back to School Imm Requirements Poster 11 x 17  
Preteen Doctor Visit 12 x 20
Got Vaxed Poster Teenagers 14 x 20  
Got Vaxed Poster Question Mark 14 x 20  
Vaccinate Before You Graduate 11 x 17  
Brochures A Guide for Parents about USIIS (100)
Hepatitis A What You Should Know (50)
Got Vaxed Adolescent (100)
Preteen Doctor Visit (100)
Protect Children by Protecting Yourself (100)
The Utah School Immunization Rule (100)
Vaccinate Before You Graduate (100)
Your Child & Vaccine Safety (50)
Tearpads VFC Information Tearpad double-sided English/Spanish (50)  
Please verify your order by entering the random letters (case sensitive) displayed in this image:

Contact Tammy Gresham with any questions (801) 538-9450. Include quantities that will be sufficient for a three month period.