2025 Hancock County Health Department School-Based Flu Vaccine Consent Form

  • 2025 Hancock County Health Department School-Based Flu Vaccine Consent Form

  • Section 1: Information about Student to Receive Influenza Vaccine 

  • Student's Date of Birth*
     - -
  • Gender*
  • Ethnicity*
  • Race*
  • Format: (000) 000-0000.
  • Do you have insurance that covers vaccines?*
  • Please choose health insurance provider:

  • Provide the insurance information for the provider selected &  attach  a copy of the insurance card to this form

  • Policy Holder Date of Birth
     - -
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  • Section 2: Medical Information

    The following questions will help us to determine if this student can receive the influenza vaccine.    

    *Please choose Yes or No for each question.

  • Has the student received any vaccines in the past 4 weeks?*
  • Has the student ever had a serious reaction to eggs?*
  • Has the student ever had a serious reaction to any influenza vaccine?*
  • Does the child use an inhaler or receive breathing treatments for asthma or wheezing condition?*
  • Is the student on long term aspirin or aspirin-containing therapy (For example: does the student take aspirin every day)?*
  • Does the student have any significant or chronic (long term) health conditions? (For example: diabetes, sickle cell disease, heart conditions, lung conditions, seizure disorders, cerebral palsy, muscle or nerve disorders.)*
  • Does the student have a weak immune system? (For example: from HIV, cancer, or medications such as steroids or those used to treat cancer.)*
  • Is the student or could the student be pregnant?*
  • Has the student ever had Guillain-Barre Syndrome (GBS)?*

  • Section 3: Consent

    If this consent form is not filled in completely, signed, dated, and returned, the student will not be vaccinated at school.

  • I GIVE CONSENT to the North Central Health District (NCHD) for the student named above to receive the influenza vaccine.  I acknowledge that the student and medical information provided above is correct. I have been given a copy of the Vaccine Information Statements for the influenza vaccines.  I have had a chance to ask questions which were answered to my satisfaction. I acknowledge that I have reviewed and understand the Notice of Privacy Practices for NCHD which is available at northcentratlhealthdistrict.org or at my local health department.  I understand the benefits and risks of the influenza vaccine that will be given to the student that I am authorized to represent.  I understand that participation and receipt of the influenza vaccine through this program is completely voluntary.  By signing below, I give permission for the student listed above to receive the influenza vaccine. 

    • CDC Influenza Vaccine Information Sheet
    • NCHD Privacy Policy
  • Date of Signature*
     - -
  • Should be Empty: