VACCINE CONSENT FORM

Personal Information

IF YOUR SCHOOL'S CLINIC IS WITHIN THE NEXT 2 SCHOOL DAYS, YOUR
REGISTRATION MAY NOT BE REVIEWED IN TIME. YOUR TEEN WILL BE SCHEDULED
FOR THE NEXT CLINIC. 
Gender: *

Health Insurance Information

Medical Screening for Vaccine Eligibility

1. Does your child have allergies to medications, food, or any vaccine? *
2. Has your child ever had a serious reaction to a vaccine in the past? *
3. Has your child, a sibling, or a parent ever had a seizure or brain problem? *
4. Does your child have cancer, leukemia, HIV/AIDS, or any other immune system condition? *
5. Does your child take cortisone, prednisone, steroids or anti-cancer drugs or had radiation treatment? *
6. Has your child received a blood transfusion, blood products, or been given immune (gamma) globulin in the past year? *
7. Has your child received any vaccinations in the past 4 weeks or taken an antiviral drug? *

Consent for Vaccination in the School Setting

I have viewed the Vaccine Information Statement(s) for the vaccine(s) requested, using the link below.
I understand the benefits and risks of the vaccine(s) requested.
 
I understand that a record of vaccinations administered in this program will be submitted to the statewide database, KIDSNET within 48 hours of vaccination.  I hereby release The Wellness Company from any and all liability associated with the administration and potential side effects of the vaccine.
 I would like my child to receive this vaccine
Hepatitis A (2 doses)
Hepatitis B (3 doses)
HPV - Gardasil (Human Papillomavirus- 2-3 doses)
MMR (Measles, Mumps & Rubella - 2 doses)
Meningitis A, C, W, Y (1-2 doses, required)
Polio (3-4 doses)
Tdap (Tetanus, Diphtheria, Pertussis)/Td
Serogroup B Meningococcal (2 doses recommended for college)
Varicella - Chicken Pox (2 doses)
The vaccines checked above should be given to the student named for whom I am authorized to make this request. I understand all doses indicated for each vaccine are needed to receive full protection. My signature here certifies and confirms my consent.

Please sign using your stylus, finger, or mouse. *
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