Maine Department of Education
Permanent Individual Student Health Record

Order Form

Name/Title:__________________________________________________________________________
School/District: _____________________________________________________________________
Address: ___________________________________________________________________________
___________________________________________________________________________________

E-mail Address:  ____________________________________________________________________

Phone # ________________________	

For School Year (2015-16, 2016-17, etc.) (required) _______________________________________

Name(s) of School(s) for whom records will be used:*
NOTE:  Please only order what you will use within two years. 

_____________________________________________________________________________________

Permanent Individual Student Health Record 
Quantity ________ X $.40  =         		_________   (Shipping included)
Quantity ________ X $.30 =	          		_________   (If picked up in person)	
Total amount due	  	                    	 ________________________

Please make check payable to “Treasurer, State of Maine” and mail this form along with check or P.O. to:  

		Cristina Stade
		Maine Department of Education
		23 State House Station
		Augusta Me 04333-0023
		Tel # 624-6694
		Fax # 624-6651
		e-mail:  Cristina.stade@maine.gov

*As a rule, transferring students should be followed by their health records.  If they are not, and you need to start a new record for a transfer student.  For more information, contact Cristina Stade at 624-6694 or Cristina.stade@maine.gov										
9/2018