Consent for Immunizations

PLEASE COMPLETE SECTIONS 1 AND 2

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Section 1: Child’s Personal Information

Grade:

7

8

9

School:

Teacher's Name (Homeroom):

Child’s Last Name:

Child’s First Name:

Preferred First name:

Date of Birth:

Gender at Birth:

M

F

Identifies as:

M

F

X

Medicare Number:

Parent/Legal Guardian Last Name:

Parent/Legal Guardian First Name:

Preferred Language for Correspondence:

English

French

Daytime Phone:

Cell

Other Daytime Phone:

Cell

Parent/Legal Guardian Email:

Confirm Parent Email:

Does your child have allergies?

No

Yes

If yes, to what and what type of reaction?:

Does your child have a health problem?

No

Yes

Please explain:

Does your child take any medications?

No

Yes

Please list: