HPV Notification

HPV Information Form

 Dear Parent or Gaurdian,

A new Indiana Law requires that parents/guardians be informed "about Human Papillamavirus and its vaccine" (IC 20-34-4-5.5). 

Human papillomavirus (HPV) is a virus that young women can contract through sexual contact.  There are many differnet strains of this virus some of which can later cause cervical cancer.  In most instances, a woman will not know that she has the virus.  There is no cure for cervical cancer; however, there is an immunization available that has significantly decreased the incidence of developing cervical cancer.

The State of Indiana IC 20-34-4-5.5 states each parent of a 6th grade female student shall be required to furnish no later than 20 days after the first day of school, a written statement stating the current status of their daughter. 

HPV Information Form

Student Name

Please respond by checking the appropriate Option

My daughter has received or is receiving the immunization

I have decided not to have my daughter immunized

I have decided not to provide the school with the information concerning this immunization

I have received information concerning human papillomavirus. 


I have read and understand the HPV form listed above






When you have completed this form, please select the Submit button below

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