2025 Student School Based Flu Vaccine Clinic (Public School)

Student School Based Influenza (Flu) Vaccine Clinic for Public Schools

Patient Registration Form
Student's Legal Last Name*
Student's Legal First Name*
Student's Date of Birth*

MonthDayYear
Student's Primary Language*
Student's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student's Race*
Student's Ethnicity*
Student's Gender At Birth*
Primary Parent/Guardian Phone Number*
Please enter a valid phone number.
Primary Parent/Guardian Email*
example@example.com
Primary Parent/Guardian Last Name*
Primary Parent/Guardian First Name*
If I cannot be reached in the case of emergency, please call*

Last NameFirst Name
Emergency Contact Phone Number *
Please enter a valid phone number.
Emergency Contact's Relation to Student*
What School Does The Student Attend?
Student's Grade
Does The Student Have Primary Health Insurance and/or Medicaid?*
If YES, the student has health insurance:

Complete the questions below.
What is the name of the health insurance provider?
How is the policy holder related to the student?
What is the name of the insurance policy holder?

Last NameFirst Name
What is the birth date of the policy holder?

MonthDayYear
Date
What is the gender of the policy holder? .
What is the address of the policy holder?

Street Address

Street Address Line 2

CityState

Zip Code
What is the policy holder's phone number?
Please enter a valid phone number.
What is the Member ID Number/Subscriber Number?
For Tricare, use BENEFITS number on back of CAC card.
What is the Group Number? .
Attach a photo or scanned copy of the FRONT of the health insurance card.

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Attach a photo or scanned copy of the BACK of the health insurance card.

Cancelof
If patient is 18 years or younger:
General consent for treatment

By signing below, I hereby authorize the County Health Department to render the appropriate services and presumptive treatment to my child at my request. I understand that to render care, the staff may need to examine, conduct tests or diagnositc procedures, administer medicines or treatments to my child. I understand that I will have an opportunity to ask my healthcare provider questions regarding such care and read any informational materials given to me as deemed appropriate. I acknowledge that all of the information I have provided to the County Health Department staff is true and accurate to the best of my knowledge.

Vaccine(s) given to my child will be administered by a licensed nurse. I understand that the vaccine(s) received are recommended by the Center for Disease Control (CDC) for the prevention of the disease indicated.

Consent for emergency medical treatment

Should my child need immediate medical attention, the teacher(s) have my permission to seek immediate medical treatment. My signature below indicates my consent to emergency medical treatment.
Signature*

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My child has had:*

A severe allergic reaction to the flu vaccine or any other vaccine.A severe allergic reaction to a previous medication.A history of Guillian-Barre syndrome, uncontrolled seizures.A fever of 101 degrees within the past 24 hours.None of the above.
If anything was marked above, please list and explain below.
North Central Health District Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have reviewed and understand the Notice of Privacy Practices for the North Central Health District. The Notice sets forth the ways in which my personal health information may be used or disclosed by the North Central Health District or the County Health Department and outlines my rights with respect to such information.
Signature*

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Media Release

By signing below, I grant permission for North Central Health District and/or Houston County School District to use their photographs in publications, both print and digital forms, including the companies' websites, newsletters, emails, social media posts, videos, brochures, and advertisements. In giving this consent, I release North Central Health District and/or Houston County School District and all third parties from liability for any violation of my personal or proprietary right that either may have in connection with the reproduction or use of their photographs or videos.
Media Release Consent or Decline*

I Consent to Media ReleaseI DO NOT Consent
Signature

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Student School Based Influenza (Flu) Vaccine Clinic for Public Schools

If YES, the student has health insurance:

If patient is 18 years or younger:

Media Release