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?

TwinTriplet
Gender*

MaleFemale
Mailing Address*
EX: 1234 Hawaii Street
City*
EX: Honolulu
State*
Zip Code*
ex: 96813
Phone Number*
Please enter a valid phone number.
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*

Clear
Date Signed

MonthDayYear
01/01/2025
Should be Empty:

Parent's/Guardian Information