Authorization and Consent to Immunize

Authorize & Consent to Immunize
Delegation of Authority to Consent to Immunizations (a parent may given written authority to another adult [18 years and older] to consent to immunize their child in the parent's absence).

Please complete the following form and haev it turned in during the child's immunization appointment.
I, Parent/Guardian*, authorize and consent for Adult Bringing Child* to bring my child, Child's Name* , to the Platte County Health Department to receive their immunization.
I agree for my child to receive the following immunizations and verify that I have read the Vaccine Information Statements (VIS) for each vaccine they are to receive as well as the Emergency Use Authorization Form (EUA) for the COVID-19 Vaccine.
Vaccine(s) Consent to Administer*

DTaP (Diphtheria, Tetanus, Pertussis)Hepatitis AHepatitis BHib (Haemophilus influenzae BHPV (Human Papillomavirus)Influenza (Flu)MenACWY (Meningitis ACWY)MenB (Meningitis B)MMR (Measles, Mumps, Rubella)MMRV (Measles, Mumps, Rubella, Varicella)PCV13 (Pneumococcal)PPSV (Pneumococcal, for specific health conditions)PolioRotavirusTd (Tetanus/Diphtheria)Tdap (Tetanus, Diphtheria, Pertussis)TyphoidVaricella (Chickenpox)Yellow FeverCOVID-19
Signature of Parent or Legal Guardian*

Clear
Print Name*
Relationship to Child*
Parent, Legal Guardian, etc.
Date of Signature*

MonthDayYear
Date
Should be Empty:

Authorize & Consent to Immunize