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Vaccine Clinic Registration
Register to participate in Super Shot's vaccine clinic on September 23 at Ivy Tech. We will be offering vaccines for flu, COVID and any program requirements. Please reach out to Super Shot with any vaccine questions at info@supershot.org
Student's Full Name
*
First Name
Last Name
Student's Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student's Sex
*
Please Select
Male
Female
Student's Home Address
*
Street Address
Apartment # or Lot #
City
State / Province
Postal / Zip Code
Student's Race
*
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Burmese
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
Declined
Student's Ethnicity
*
Please Select
Hispanic/Latino
Not Hispanic/Latino
Declined
Language spoken at home
*
Please Select
English
Spanish
Burmese
Other
Is the student disabled?
Yes
No
Prefer not to say
Does the student have any of the following:
ADHD
Autism or ASD
Anxiety or Depression
ODD
Hearing Loss/Deafness
Blindness/Vision Loss
Physical impairment in one or more limb
Learning or intellectual impairment
Neurological disorder (epilepsy, MS, muscular dystrophy, etc)
Speech or language difficulties
None of these apply
Other
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Parent or Guardian Contact Information
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Number of people in household
Current Household Income
Please Select
Below $11,800
$11,800-$24,300
$24,301-$36,450
$36,451-$48,600
$48,601-$60,750
$60,751-$72,900
Over $72,901
Decline to Answer
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Required Health Insurance Information
Select the Student's insurance:
*
Private Insurance-Provided through Employer or Marketplace (examples: CIGNA, PHP, BCBS, Signature Care)
TRICARE
Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise, CareSource)
No Insurance
I certify that the student is not covered by any health insurance
*
Yes
No
Insurance Company
*
Member ID
*
DoD ID Number
*
Group Number
*
Policy Holder's Name
*
First Name
Last Name
Policy Holder's Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number
*
The service member's SSN is required for processing
Policy Holder's Relationship to Student
*
Upload Insurance Card Image (Front)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Insurance Card Image (Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Medical Information
Please answer all questions. Answers are for the student receiving the vaccines.
Is the student allergic to a vaccine component or latex (ex: gentamicin, alginine, gelatin, MSG)
*
Yes
No
List vaccine component allergies:
*
Has the student had a serious reaction to a vaccine in the past?
*
Yes
No
Describe the serious reaction:
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Is the student pregnant or is there a chance they could become pregnant within a month of being vaccinated?
*
Yes
No
Not Applicable
Is someone in the student's home immunocompromised or requires a protective environment?
*
Yes
No
Does the student have any of the following conditions:
*
ADHD
Anxiety or Depression
Asplenia
Autism or ASD
Blindness/Vision Loss
Chronic Heart Disease
CSF Leak
Diagnosed with Myocarditis or MIS-C
Diabetes/Metabolic Disorder
Hearing Loss/Deafness
History of Chickenpox
History or Family History of a Nervous System Disorder
History of Gillian-Barre Syndrome
Kidney Disease
Learning or intellectual impairment
Liver Disease
Neurological disorder (epilepsy, MS, muscular dystrophy, etc)
ODD
Physical impairment in one or more limb
Psoriasis
Received blood products or immune gamma globulin in the last year
Speech or language difficulties
Takes a medication that lowers resistance to infection
Takes aspirin or blood thinners
Weakened Immune System, Cancer, Lupus, HIV/AIDS
None of these apply
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Consent
The following vaccines may be required by your school and/or program. A recommended vaccine may also be suggested by age group to prevent illness and/or cancer, but is not required. Your school nurse or a Super Shot representative will review any Indiana shot record to review which vaccines are needed. More information about any of these vaccines are available with information sheets at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html Please select which vaccines you wish to receive:
I consent to receiving the following recommended vaccines:
*
Flu shot (Influenza)-recommended annually for all persons 6 months+
Flu Mist - Live Attenuated Intranasal Influenza Vaccine (recommended for age 2 through 49 years)
Updated COVID vaccine for the 2026-27 season
Pneumococcal (recommended for age 50+ or those younger with risk factors)
MMR (Measles, Mumps, Rubella)
Hep B (Hepatitis B, required by most clinical/medical schools)
Varicella (Chicken Pox)
Tdap (Tetanus, Diphtheria, Pertussis)
MenB-Prevents B strain of Meningitis. This strain accounts for 9 out of 10 cases of Meningitis for young people. Some colleges and the military require this vaccine. This is administered as a combination vaccine, Penmenvy, when given with Meningitis ACWY. All strains (ABCWY) are included in this one vaccine. MenB is a 2 dose series, spaced 6 months apart.
HPV-Prevents 9 strains of Human Papilloma Viruses that can cause head, neck, cervical, vaginal, vulvar, penile, and anal cancers.
Other-if there are other vaccines you may be due for, Super Shot will reach out to you prior to your clinic date to ensure we have this vaccine available
U.S. Centers for Disease Control and Prevention (CDC) now recommends COVID-19 vaccines for adults and children at risk for severe disease. The COVID-19 vaccine is indicated for those less than 65 years old as follows: (1) those that have consulted with a medical professional and determined that the vaccination is appropriate and/or (2) those with any risk factors at https://www.cdc.gov/covid/risk-factors/index.htm
I have read the following recommendation and should receive my COVID vaccine at this time
U.S. Centers for Disease Control and Prevention (CDC) recommends the 21-valent pneumococcal vaccine (PCV21, Capvaxive) for all adults age 50 and older.Adults younger than 50 may also need this vaccine if they have certain health conditions that increase their risk. You can learn more about those risk factors on the CDC website: https://www.cdc.gov/pneumococcal/causes/index.html#cdc_causes_risk-risk-factors
I have read the following recommendation and should receive my Pneumococcal vaccine at this time
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Communication Preference:
*
It is OK to call me
It is OK to text me
The HIPAA Notice of Privacy Policy available at https://supershot.org/privacy-policy/ CDC Vaccine Information Statements for all vaccines the person named above will receive are available at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html I have read and understand all information provided at the links above and understand the benefits of vaccines, as well as the risks which includes the contraindications, precautions, and possible side effects of each vaccine administered. I give permission to Super Shot to communicate information provided with other healthcare providers as needed, for EMR data entry, insurance billing for services provided, and storage according to Indiana Department of Health policies. I relieve Super Shot, Inc and all personnel of any liability for any reactions that may occur. I have the legal authority, based on my relationship to the person named above, to consent to this vaccine administration.
Patient Signature
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Patient Name:
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Today's Date
*
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Register
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