• School Required Vaccine Consent Form

    Must be completed by a parent/guardian if under the age of 18.

  • Dear Parent(s) or Guardian:

    Missouri state immunization requirements mandate that students entering Pre K/ Kindergarten, 8th grade and 12th grade receive specific vaccinations prior to the start of the school year. 

    Vaccine information and educational resources are provided below. By completing, signing and submitting this online form, you authorize us to administer the vaccines you have selected for your child.

    VACCINE INFORMATION:

    *Click on the heading to be linked to CDC website for more information on the vaccine.

    8th Grade (Required)

    TDap (Tetanus, Diphtheria, Pertussis)

    Meningococcal ACWY

     

    12th Grade (Required)

    Meningococcal ACWY

     

    8th & 12th Grade (Optional-Highly Recommended)

    Meningococcal B Vaccine (Optional & Highly Recommended)

    Shared Clinical Decision Making Meningococcal B

     

     

     If you have additional questions about these clinics or the vaccines, please contact your school nurse or one of our Public Health Staff listed below.

     Thank You,

    Pike County Health Dept. Public Health Staff

    Jeannie Stuckey (jstuckey@pikecountyhealth.org)

    Robyn Orf (rorf@pikecountyhealth.org)

    573-324-2111

  • Student Information

  • Select County*
  • Date of Birth*
     - -
  • Gender*
  • Ethnicity*

  • Parent/Guardian Information

  • Parent/Guardian Date of Birth*
     - -
  • Address same as Child's*
  • Format: (000) 000-0000.

  • Vaccine Consent

    PLEASE SELECT THE VACCINES YOU CHOOSE YOUR CHILD TO RECEIVE
  • Will your child be participating in the PCHD Back 2 School Drive thru clinic on August 18th, 2026?*
  • NO, my child will not be attending the PCHD Back 2 School Drive thru clinic on August 18th, 2026. Please contact me to schedule an appointment for the vaccines I have selected. I understand I will need to sign a new consent on the date the vaccines will be given.
  • Grade child is entering*
  • 8th Grade REQUIRED: Please mark the vaccines you would like your child to receive*
  • 8th Grade OPTIONAL: Please mark if you would like your child to receive this vaccine
  • 12th Grade OPTIONAL: Please mark if you would like your child to receive this vaccine
  • I understand that by signing and submitting this form that I am given consent for my child to receive the vaccines I have selected at the PCHD Back 2 School Drive thru event on August 18th, 2026. I understand that if my child is unable to attend on this date that this consent will be invalid and that I will need to submit a new consent for any future dates.

  • For Patients:   The following questions will help us determine which vaccine you may be given today. If you answer “YES” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask you healthcare provider to explain.

  • 1. Has your child ever had an adverse reaction or complications to ANY vaccines received in the past?*
  • 2. Is your child allergic to ANY vaccine components or latex.?*
  • 3. Has your child had any brain or nervous system problems or Guillain-Barre Syndrome.?*
  • 4. Is your FEMALE child pregnant?*

  • Insurance Information

  • Choose only one
  • Format: (000) 000-0000.
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  • Additional Consent/Information

  • Withdrawal of consent

    You may withdraw your consent at any time by calling Pike County Health Department at 573-324-2111. Staff will send a confirmation email/mailed paper copy for verification. Withdrawal will not affect services already rendered, but may impact ongoing service delivery

  • Today's Date*
     - -
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