Pender County Schools Permission Form for Flu Vaccine

SEASONAL FLU
INFORMATION & CONSENT FORM

September 15, 2025

Dear Parent/Guardian:

We are pleased to announce that Pender County Health Department, in collaboration with the Pender County Schools, will be offering flu shots at your child’s school again this year in the months of October and November. This immunization opportunity will be available to all students and staff in our county school system. The vaccine will be administered by health department nurses to those who are able to receive the flu vaccine and have written parental permission. State vaccine will be available for children who do not have insurance.

The flu is very contagious. Flu in children can be serious and can cause fever, headache, extreme tiredness and body aches. Children can be sick with the flu for a week and should be absent from school and childcare during that time.

The single best way to prevent the flu is to get a flu vaccination each year. The Centers for Disease Control and Prevention (CDC) recommend that all children be vaccinated against the flu. Our goal for this immunization initiative is to prevent students from being sick with the flu and spreading it to their classmates, family and others in the community. To read more about the flu vaccine, click on the Vaccine Information Sheet link below.

Vaccine Information Statement Link

Please click on the link below to complete and sign the digital consent form. The Health Department staff will contact you with any questions. You will need to complete the form granting permission for your child to be vaccinated against the flu and provide your child’s insurance information by October 15, 2025. We are unable to vaccinate anyone without a completed form and the parent or guardian’s signature.

If you have any questions, please contact the Pender County Health Department at
(910) 259-1230, or your child’s healthcare provider. Carefully consider this opportunity for your child(ren).

Sincerely,

Pender County Health Department
2025-2026 PENDER COUNTY SCHOOLS PERMISSION FORM FOR FLU VACCINE

TO BE COMPLETED BY PARENT/GUARDIAN
Pender County Health Department
803 S. Walker Street, Burgaw, NC 28425
(910) 259-1230
School Name*
Homeroom Teacher*
Full Name*
Date of Birth*

MonthDayYear
Date
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Mothers Maiden Name:*
Responsible Person:*
Race*

AsianBlack/African AmericanAmerican Indian/Alaskan NativeNative Hawaiian/Pacific IslanderWhite
Ethnicity*

Not Hispanic/LatinoHispanic
Gender*

MaleFemale
Please answer the following questions by checking the appropriate answer:
Has your child ever experienced an allergic reaction after receiving a dose of flu vaccine?*

YesNo
Has your child ever experienced Guillain-Barre Syndrome after receiving a flu vaccine or have a history of Guillain-Barre Syndrome?*

YesNo
Is your child currently pregnant?*

YesNo
INSURANCE INFORMATION/AUTHORIZATION TO BILL
Does your child have insurance?*

YesNo
Insurance Name*
Member ID*
Group Number*
Phone Number
Medical Claims Address
Subscriber Name*
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber Social Security Number (if Tricare)
Subscriber Address
PERMISSION TO VACCINATE CHILD AND FILE APPLICABLE INSURANCE

I give permission for the above child to receive the vaccine being provided by the Pender County Health Department in Pender County Schools. I have received and read the appropriate Vaccine Information Statement. I understand that I may access the Pender County Health Department Notice of Privacy Practices by visiting http://health.pendercountync.gov/ and may call 910-259-1230 to obtain a copy or to address any concerns.

I authorize payment from 3rd Party Payer (Insurance) and Medicaid be made on my behalf to Pender County Health Department (PCHD) for services provided. I understand that my signature will serve as legal "signature on file" for purposes of filing Insurance/Medicaid claims and payment of benefits to the PCHD for services rendered.
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty:

2025-2026 PENDER COUNTY SCHOOLS PERMISSION FORM FOR FLU VACCINE