School Required Vaccination

Dear Parent(s) or Guardian:

Incoming 8th & 12th graders are required by the State of Missouri to have certain vaccines before the start of each school year. Our agency provides these vaccines to students at their schools, mobile clinics and at our Walk-In-Clinic.

We have provided vaccine information and links below and by filling out this online form, it will grant us the permission to administer these required vaccines to your child.

VACCINE INFORMATION:

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

TDap Vaccine (Required for Incoming 8th Graders)

Protects against Tetanus, Diphtheria, and pertussis/whooping cough. Tetanus, diphtheria and pertussis can be very serious diseases, even for adolescents and adults. Tdap vaccine can protect us from these diseases.

Meningococcal ACWY Vaccine (Required for Incoming 8th & 12th Graders)

Meningococcal disease is a serious bacterial illness that can be fatal quickly. It is an infection of the covering of the brain and the spinal cord and can cause blood infections. We will be offering Menquadfi (includes strands A, C, Y and W).

Meningococcal B Vaccine (Optional & Highly Recommended)

Shared Clinical Decision Making Meningococcal B

Helps protect against meningococcal disease caused by serogroup B. A different meningococcal vaccine is available that can help protect against serogroups A, C, W, and Y.

HPV Vaccine (Optional. Offered only in our Walk-In-Clinic)

HPV, or human papillomavirus, is a common virus that can cause cancers later in life. HPV vaccination prevents new HPV infections but does not treat existing HPV infections or diseases. HPV is spread through intimate skin-to-skin contact. You can get HPV by having vaginal, anal, or oral sex with someone who has the virus, even if they don't have signs or symptoms. This is available daily at our office Walk-In-Clinic hours (M-F 8am-12pm/1pm-4pm)

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

Bowling Green 3/25/26Clopton 3/19/26Louisiana 3/19/26Van Far 3/11/26

Name of Child*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

MaleFemale

Age

Race*

Preferred Language:*

Not HispanicHispanic

Name of Parent/Guardian*

First NameLast Name

Allergies

Parent/Guardian Date of Birth*

Date

Email

example@example.com

YesNo

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship to Child*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Meningococcal ACWY: REQUIRED for all incoming 8th & 12th Graders.Tdap (Tetanus, Diphtheria, Pertussis): REQUIRED for all incoming 8th Graders.

YES to Meningococcal B: RECOMMENDED for all incoming 8th & 12th Graders.NO to Meningococcal B: RECOMMENDED for all incoming 8th & 12th Graders.

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.

Answer Yes or No to each question *

Rows	Yes	No
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?

Answer Yes or No to each question *

Rows	Yes	No
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.?

No Insurance or Under insuredAmerican Indian or Alaska NativeDoes not apply to me

Insurance Name

Member ID Number *

Group Number*

Contact Phone # for Insurance*

Please enter a valid phone number.Format: (000) 000-0000.

Upload a copy of your insurance card here, or take a picture and add below

Please Take Photo of the front of your insurance card here.

Please Take Photo of the back of your insurance card here.

By signing this form, I am stating that I have read or have had explained to me the information on this form. I believe I understand the benefits and risk of the vaccine(s). I have chosen to request the vaccine be given to me or the person named above for whom I authorized the request.

Parent/Guardian Signature*

Today's Date*

Date

Please use this space for any comments/questions you may have:

School Required Vaccine Consent Form

Student Information

Parent/Guardian Information

Vaccine Consent

Insurance Information

Additional Consent/Information