Section 1: Information about Student to Receive Influenza Vaccine
Provide the insurance information for the provider selected & attach a copy of the insurance card to this form
Section 2: Medical Information
The following questions will help us to determine if this student can receive the influenza vaccine.
*Please choose Yes or No for each question.
Section 3: Consent
If this consent form is not filled in completely, signed, dated, and returned, the student will not be vaccinated at school.
I GIVE CONSENT to the North Central Health District (NCHD) for the student named above to receive the influenza vaccine. I acknowledge that the student and medical information provided above is correct. I have been given a copy of the Vaccine Information Statements for the influenza vaccines. I have had a chance to ask questions which were answered to my satisfaction. I acknowledge that I have reviewed and understand the Notice of Privacy Practices for NCHD which is available at northcentratlhealthdistrict.org or at my local health department. I understand the benefits and risks of the influenza vaccine that will be given to the student that I am authorized to represent. I understand that participation and receipt of the influenza vaccine through this program is completely voluntary. By signing below, I give permission for the student listed above to receive the influenza vaccine.