TopBridge Academy

Health & Immunization Records

Florida DOE Compliant • Form DH 3040 / DH 680 Equivalent

Required before enrollment. Download your signed PDF and submit to the school office.

Fill all required fields, select completed immunizations, sign at the bottom, then tap Sign, Download & Submit.

Student Information

Student Name *

Date of Birth *

Grade *

Insurance Information

Insurance Provider

Policy Number

Group Number

Physician & Exam Dates

Physician Name *

Physician Phone *

Last Physical Exam Date

Immunization Certificate Date

Florida Required Immunizations

Check all immunizations your child has completed. Upload official documentation to the school office.

Note: Additional doses may be required depending on age and schedule.

Medical Information

Medical Conditions

0/500

Allergies

0/500

Current Medications

0/500

Additional Notes

0/500

Parent / Guardian Signature

By signing below, I certify that the health and immunization information provided is accurate to the best of my knowledge, and I authorize TopBridge Academy to seek emergency medical treatment for my child if necessary.

Digital Signature *

Sign here with your finger or mouse

Printed Name *

Date *

Your PDF will download automatically. A copy is also sent to the school office.