Spring School Immunization Consent Form 2026

School Immunization Consent Form 2026

Macon County Health Department
Dear parent/guardian,

You may have heard recently that the CDC changed their recommended immunization schedule. While this is true, the state of Missouri has not changed their requirements for students to attend MO public schools and we are continuing to recommend the same vaccines for children and teens that we have in the past. The Macon County Health Department has these required and recommended vaccines available and plan to offer them at the schools throughout Macon County this spring for students entering 8th and 12th grades for the upcoming 2026-2027 school year, who will need to be compliant with state regulations.

Vaccines to be offered:
TDaP (tetanus, diptheria, & pertussis): required for all incoming 8th graders

Meningococcal (meningitis): required for all incoming 8th & 12th graders

HPV (human papilloma virus): recommended for all teens, but not required to attend public school

*Please note that HPV and some Meningococcal vaccines are multi-dose series and will need to be followed up on with subsequent booster doses if you choose for your teen to receive either of them.

This is a great opportunity for your teens to get up to date on their immunizations for the next school year without making an appointment anywhere or missing school/work! Please see below for the date that Macon County Health Department will be at your teen's respective school. For any questions related to any vaccines being offered, please call the Macon County Health Department (660-395-4711) to speak with one of our nurses. We have vaccines for those insured and uninsured! (We encourage you to contact your insurance company prior to immunizations to verify coverage if you are unsure)

School Immunization Dates

Callao: TBD

New Cambria: TBD

Macon: April 13

Bevier: April 2

Atlanta: TBD

La Plata: May 13

https://downloads.aap.org/AAP/PDF/AAP-Immunization-Schedule.pdf

Macon County Health Department

503 N. Missouri St.

Macon, MO 63552

660-395-4711
Atlanta C3Bevier C4Callao C8La Plata R2Macon R1Macon County R4
Patient Information
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Student's Current Grade Level*
MaleFemale
WhiteAfrican AmericanBi-racialAsianAmerican Indian/Alaskan NativeOther
Not Hispanic or LatinoHispanic or Latino
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Format: (000) 000-0000.
TDaP (tetanus, diptheria, pertussis) (required for those entering 8th grade)Meningococcal (ACWY) (required for those entering 8th & 12th grade)HPV (human papilloma virus) (recommended for any teen who has not already completed)Meningococcal B (recommended for those going into 12th grade who plan on living on campus or entering the military post HS graduation)
Student Health History
For parents/guardians: The following questions will help us determine if the vaccines offered may be given to your teen. If you answer “yes” to any question, it does not mean your teen should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

Vaccine History *

Rows	Yes	No	If Yes, Please Explain
Does your teen have any allergies?
Has your teen ever had a reaction following a vaccine?
Has your teen had brain or other nervous system problem?
Does your child have a weakened immune system due to any disease that effects immune system, long term use with steroids, or cancer treatment with radiation or medications?
Is your teen sick today?

Insurance Company Name (please put NONE if no insurance)*
Insurance ID # / Medicaid DCN #*
Insurance Group Number (if applicable)*
Insurance Policy Holder's Name (if Parent/Guardian is primary)*
Insurance Card-- PLEASE UPLOAD INSURANCE CARD IF AVAILABLE

Cancelof
By signing below, I request and authorize the minor student named above to receive vaccine(s) from the Macon County Health Department as marked on this consent form and to receive any and all health care services available from and deemed necessary by the staff of the vaccination site in the rare event of an adverse reaction following vaccination.

I am also requesting that payment of authorized Medicaid/Third Party Insurance benefits be made on my behalf to the Macon County Health Department for any services furnished by their professional staff. I authorize any holder of medical information about me/my child to release any information needed to determine these benefits payable for related services. If your insurance opts to decline coverage for the vaccine(s) deemed necessary, you will receive a bill from Macon County Health Department and agree to pay the difference. We encourage you to contact your insurance company prior to immunizations to verify coverage if you are unsure.

I understand that I have the right to revoke this one time consent at any time. I understand that if I revoke permission, I must do so in writing and present my notification to Macon County Health Department prior to the date of the respective school's immunization clinic.
Today's Date*

MonthDayYear
Date
Signature*

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School Immunization Consent Form 2026

Patient Information

Student Health History