Vaccine Clinic Registration form

Vaccine Clinic Registration form

Whittier Elementary October 22nd, 2024 3pm-7pm
COVID AND FLU VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS.
Patient's Name

First NameLast Name
Birth Date

MonthDayYear
Sex

MaleFemale
Gender Identity

MaleFemaleNon-BinaryOther
Parent/Caregiver's Name
Relationship to the patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
Phone Number
Racial Identity

WhiteBlackAsianNative Hawaiian or Pacific IslanderAmerican Indian/Alaska NativeOther
Ethnicity

Hispanic/LatinoNot Hispanic/Latino
Insurance Provider *INSURANCE IS NOT REQUIRED*

Regence BCBSPremeraKaiserAetnaMolina Apple HealthProviderOne or Other Apple Health PlanFirst Choice Health NetworkCignaOther
Insurance ID Number
Insurance Group Number
Insurance Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Other Information
Picture of Insurance Card

Cancelof
I would like my child to receive the following vaccines:

Flu VaccineCOVID VaccineFlu and COVID Vaccine
I would like my child to receive their vaccine(s) during the school day without a parent present.

YesNo
I would like to be present for my child's vaccine(s) and I will bring them to receive their vaccines between 2:30pm and 5pm.

YesNo
Signature
Should be Empty:

COVID AND FLU VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS.