VAVR for VFC Eligible Child (2025-2026)

Vaccines for Children Program

Vaccine Administration Visit Record (VAVR)
Child's Name

First NameLast Name
M.I.
Middle Initial
Child's Date of Birth

MonthDayYear
Is the child a Twin or Triplet?
Gender
Mailing Address
EX: 1234 Hawaii Street
City
EX: Honolulu
State
Zip Code
ex: 96813
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
VFC Eligibility - 18 years of age and younger: Please check all that apply)
Parent's/Guardian Information
Parent/Guardian Name

First NameLast Name
Mothers First Name
Mothers Maiden Name
M.I.
Middle Initial
Parent/Guardian Email Address

Confirmation Emailexample@example.com
I have received and read the Vaccine Information Statements for each of the vaccines to be administered. In addition, I have received information regarding the Hawaii Immunization Registry.
Parent/Guardian Signature
Date Signed

MonthDayYear
01/01/2025
Should be Empty:

Parent's/Guardian Information