Flu Information & Registration

School Flu Form 2026

By submitting this form, you agree to allow your child to receive the flu vaccine at school
Dear Parents and/or Guardians:

Welcome back to a new school year! Langlade County Health Department will be offering 2026-2027 influenza vaccine, free, at your school. The Center for Disease Control and the American Academy of Pediatrics recommend that all children 6 months and older receive an annual influenza vaccination. This program is voluntary and provided at no cost to you.

All students ages 4 and up will be able to receive the influenza vaccine during the school day, without a parent being present, if you believe your child will be cooperative. Influenza vaccinations will be given on the following days:

Antigo Middle School - Friday, October 9th

West Elementary - Tuesday, October 13th

North Elementary - Wednesday, October 14th

Antigo High School - Friday, October 16th

If you have signed your child up for the influenza vaccination, and they receive it elsewhere prior to the dates listed above, please contact the Health Department so we can remove them from our list.

Your signature on the electronic form allows the health department permission to give the flu vaccine to your child.
Name of Child to Receive Flu Vaccine

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Please select from the dropdown menu the correct school for your child
Please select from the dropdown menu the correct grade for your child
Please answer the following questions so we can determine if your child can receive the 2026-2027 influenza vaccine.
Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
Has the person to be vaccinated ever had Guillain-Barre Syndrome?
By checking the box below, you acknowledge you have reviewed the Vaccine Information Statement located at the link below.

https://www.cdc.gov/vaccines/hcp/current-vis/influenza-inactivated.html
I have read the VIS at the link above
I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the vaccine be given to the person named above for whom I am authorized to make this request by the Langlade County Health Department.

I understand the Langlade County Health Department may bill Medical Assistance/Badger Care if the child is covered by those programs.

I understand that this information may be shared with my child's school and health care providers directly involved in my child's care.

I understand that this information will be entered into a statewide online vaccine registry (WIR). I give permission to share my child's immunization records including those provided to school(s) with the WIR and my immunization provider for the purpose of maintaining a complete and accurate record to assist insuring full immunizations.
Name of Parent or Guardian Responsible for Child if Under 18:

First NameLast Name
Relationship to Child:
Signature
Date Signed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have read and understood the flu information letter.
Should be Empty:

School Flu Form 2026