Immunity Sheet

New York State 4-H Dog Program Immunity Summary Sheet For the 4-H Year of: _________ Member’s Name: _________________________________, County: _______________________ Dog’s Name: _______________________________, Breed/Mix: __________________________ Age of Dog: ______________, Color _______________________________ ** Considering the typical environments 4-H Dog activities may present to a dog, it is the judgment of the veterinarian who signs this sheet, that the above mentioned dog is current on vaccines for the following diseases. The following is to be filled out and signed by a veterinarian, (AND a copy of the rabies certificate and 4 in 1 certificate must be enclosed). ____ Rabies (Rabies vaccination was given on _____________ Next rabies vaccination is due on ____________ ____ Parvovirus ____ Leptospirosis ____ Hepatitis ____ Distemper Signature of Veterinarian _____________________________, Date _________________ A copy of this should be on file in the 4-H Office and copy kept in possession of the member. This form can be used in substitution of copies of veterinary vaccination records. Can also be used in the case of titer use.