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Compliance Clinic Registration
Register to participate in the Back-to-School Immunization Clinic.
Select School Date or System
*
Please Select
Eastside Jr/Sr High 8/4 & 8/5
Concordia High 8/5 & 8/6
GKB Back to School Bash 8/6
FWCS-8/10 Back to School Night South Side
FWCS-8/10 Back to School Night
FWCS-8/11-Back to School Night Kekionga
Ivy Tech College Routine Clinic 8/25
Warsaw Community Schools 8/26
Other
Select Fort Wayne Community Schools Location
*
Please Select
Abbett
Adams
Arlington
Blackhawk
Bloomingdale
Brentwood
Bunche
Croninger
Fairfield
Forest Park
Franke Park
Glenwood Park
Haley
Harris
Harrison Hill
Holland
Indian Village
Irwin
Jefferson
Kekionga
Lakeside
Lane
Lincoln
Lindley
Maplewood
Memorial Park
Miami
New Tech Academy
North Side
Northcrest
Northrop
Northwood
Portage
Price
Scott
Shambaugh
Shawnee
Snider
South Side
St Joe
Study
Towles Intermediate
Virtual Academy
Washington
Washington Center
Wayne
Waynedale
Weisser Park
Whitney Young
Name of School
*
Grade Level for 2026-2027 School Year
*
Please Select
Kindergarten
6th Grade
11th/12th Grade
Other
Student's Full Name
*
First Name
Last Name
Student's Date of Birth
*
/
Month
/
Day
Year
Date
Student's Sex
*
Please Select
Male
Female
Student's Home Address
*
Street Address
Apartment # or Lot #
City
State / Province
Postal / Zip Code
Student's Race
*
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Burmese
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
Declined
Student's Ethnicity
*
Please Select
Hispanic/Latino
Not Hispanic/Latino
Declined
Language spoken at home
*
Please Select
English
Spanish
Burmese
Other
Student's Primary Care Provider
*
Is the student disabled?
Yes
No
Prefer not to say
Does the student have any of the following:
ADHD
Autism or ASD
Anxiety or Depression
ODD
Hearing Loss/Deafness
Blindness/Vision Loss
Physical impairment in one or more limb
Learning or intellectual impairment
Neurological disorder (epilepsy, MS, muscular dystrophy, etc)
Speech or language difficulties
None of these apply
Other
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Parent or Guardian Contact Information
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Number of people in household
Current Household Income
Please Select
Below $11,800
$11,800-$24,300
$24,301-$36,450
$36,451-$48,600
$48,601-$60,750
$60,751-$72,900
Over $72,901
Decline to Answer
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Required Health Insurance Information
Select the Student's insurance:
*
Private Insurance-Provided through Employer or Marketplace (examples: CIGNA, PHP, BCBS, Signature Care)
TRICARE
Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise, CareSource)
No Insurance
I certify that the student is not covered by any health insurance
*
Yes
No
Insurance Company
*
Member ID
*
DoD ID Number
*
Group Number
*
Policy Holder's Name
*
First Name
Last Name
Policy Holder's Date of Birth
*
/
Month
/
Day
Year
Date
Social Security Number
*
The service member's SSN is required for processing
Policy Holder's Relationship to Student
*
Upload Insurance Card Image (Front)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Insurance Card Image (Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Medical Information
Please answer all questions. Answers are for the student receiving the vaccines.
Is the student allergic to a vaccine component or latex (ex: gentamicin, alginine, gelatin, MSG)
*
Yes
No
List vaccine component allergies:
*
Has the student had a serious reaction to a vaccine in the past?
*
Yes
No
Describe the serious reaction:
*
Is the student pregnant or is there a chance they could become pregnant within a month of being vaccinated?
*
Yes
No
Not Applicable
Is someone in the student's home immunocompromised or requires a protective environment?
*
Yes
No
Does the student have any of the following conditions:
*
ADHD
Anxiety or Depression
Asplenia
Autism or ASD
Blindness/Vision Loss
Chronic Heart Disease
CSF Leak
Diagnosed with Myocarditis or MIS-C
Diabetes/Metabolic Disorder
Hearing Loss/Deafness
History of Chickenpox
History or Family History of a Nervous System Disorder
History of Gillian-Barre Syndrome
Kidney Disease
Learning or intellectual impairment
Liver Disease
Neurological disorder (epilepsy, MS, muscular dystrophy, etc)
ODD
Physical impairment in one or more limb
Psoriasis
Received blood products or immune gamma globulin in the last year
Speech or language difficulties
Takes a medication that lowers resistance to infection
Takes aspirin or blood thinners
Weakened Immune System, Cancer, Lupus, HIV/AIDS
None of these apply
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Consent
The following vaccines are required by the state of Indiana. A recommended vaccine may also be suggested by age group to prevent illness and/or cancer, but is not required. Your school nurse or a Super Shot representative will review your student's shot record to review which vaccines are needed. Your student will not receive any vaccines that are not indicated as due. Please select which vaccines you wish for your student to receive
I consent to my student receiving the following required Kindergarten vaccines:
*
Combination vaccine: MMR (Measles, Mumps, Rubella) & Varicella (Chickenpox)
Combination vaccine: DTaP (Diphtheria, Tetanus, Pertussis) & IPV (Inactivated Polio)
I understand that MMR and Varicella are live vaccines and that my child will not receive other live vaccines within 28 days of receiving this vaccine.
*
Yes
No
I consent to my student receiving the following required 6th Grade vaccines:
*
Tdap (Diphtheria, Tetanus, Pertussis)
MCV4 (Meningococcal serogroups A,C,W & Y)
I consent to my student receiving the following recommended vaccine for cancer prevention:
*
HPV-Prevents 9 strains of Human Papilloma Viruses that can cause head, neck, cervical, vaginal, vulvar, penile, and anal cancers.
I do not want my student to receive the HPV cancer preventing vaccine.
I consent to my student receiving the required 12th Grade vaccine:
*
MCV4 - second dose (Meningococcal serogroups A,C,W & Y)
I'm consenting to the combination vaccine, Penmenvy, listed below
I consent to my student receiving the following recommended 12th Grade vaccines:
*
MenB-Prevents B strain of Meningitis. This strain accounts for 9 out of 10 cases of Meningitis for young people. Some colleges and the military require this vaccine. This is administered as a combination vaccine, Penmenvy, when given with Meningitis ACWY. All strains (ABCWY) are included in this one vaccine. MenB is a 2 dose series, spaced 6 months apart.
HPV-Prevents 9 strains of Human Papilloma Viruses that can cause head, neck, cervical, vaginal, vulvar, penile, and anal cancers.
I do not want my child to receive either of these vaccines.
I consent to receive vaccine services from Super Shot. We will run your state vaccine records for Indiana and make recommendations based on record and school program requirements. If you have records from out of state that you'd like us to enter into the state CHIRP database, email them to info@supershot.org with the clinic you are attending in the subject line.
*
I consent.
I do not consent.
I consent to Super Shot providing my student catch-up doses, if needed, of any state required vaccines
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Yes, catch my student up if needed
No, do not catch my student up
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Communication Preference:
*
It is OK to call me
It is OK to text me
The HIPAA Notice of Privacy Policy available at https://supershot.org/privacy-policy/ CDC Vaccine Information Statements for all vaccines the child named above will receive are available at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html I have read and understand all information provided at the links above and understand the benefits of vaccines, as well as the risks which includes the contraindications, precautions, and possible side effects of each vaccine administered. I give permission to Super Shot to give the patient named above the vaccines selected in my absence, to communicate information provided with other healthcare providers as needed, for EMR data entry, insurance billing for services provided, and storage according to Indiana Department of Health policies. I relieve Super Shot, Inc and all personnel of any liability for any reactions that may occur. I have the legal authority, based on my relationship to the child named above, to consent to this vaccine administration.
Parent/Guardian's Signature
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Parent/Guardian's Name:
*
Today's Date
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Month
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Day
Year
Date
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