Vaccine Clinic Registration form

Vaccine Clinic Registration form

Franklin High School Wednesday, October 23rd, 2024 1pm-5pm
COVID VACCINES, ROUTINE CHILDHOOD VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS. NO INSURANCE NECESSARY.
First Name
Last Name
Sex

MaleFemale
Gender Identity

MaleFemaleNon-BinaryOther
Date of Birth

MonthDayYear
Date
Parent/Caregiver's Name
Relationship to the patient
Email Address
Phone Number
Street Address 1
Street Address 2
City
State
Zip Code
Racial Identity

WhiteBlackAsianNative Hawaiian or Pacific IslanderAmerican Indian/Alaska NativeOther
Ethnicity

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

PremeraRegence BCBSBlue Cross Blue ShieldMolina Apple HealthMolina MarketplaceKaiserFirst Choice Health NetworkAetnaCignaProviderOne or Other Apple Health PlanNo InsuranceOther
Insurance ID Number
Insurance Group Number
Insurance Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Picture of Insurance Card

Cancelof
I give consent for my child to receive:

All required and recommended childhood vaccinesCOVID VaccineAnnual Flu VaccineOnly specific vaccines (please specify below)
Other Information
Signature

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COVID VACCINES, ROUTINE CHILDHOOD VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS. NO INSURANCE NECESSARY.