Clone of 5/12/2026 Morrisville, Bristol Borough, & Bristol Township School District Vaccines for Children Consent Form

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Welcome to vaccines for kids Quakertown School District registation form.

The clinic will be held on August 26, 4:00pm-7:00pm at

Quakertown High School
600 Park Ave
Quakertown, PA 18951
We can only vaccinate children ages 3 and up. If your child is less than 3 years of age, please contact their physician to schedule a vaccination appointment.
Please select which district you are with.

Other

ACKNOWLEDGEMENTS
Privacy Policy

Click here to review Springfield Pharmacy's Privacy Policy

Vaccine Information Statements

COVID-19 VIS | Influenza VIS | DTaP VIS | Hepatits A VIS | Hepatits V VIS | HPV VIS | MMR VIS | Polio VIS | TDaP VIS | Chickenpox VIS | MCV4 VIS

Other Vaccine Information Statements can be found by clicking here
Acknowledgements

I have received a copy of the notice of Privacy Practices and appropriate CDC Vaccine Information Statement (VIS). I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Appointment
Signature of Parent/Guardian
Parent/Guardian Name
Relationship to patient
Todays Date

MonthDayYear
Date
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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