I have read the attached Centers for Disease Control and Prevention’s flu information.  I have had the opportunity to discuss this vaccine with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine.  I understand the following: 

· The purpose of and the need for the recommended vaccine

· The risks and benefits of the recommended vaccine

· The consequences my child my experience due to being unvaccinated, such as:

o   Contracting the illness the vaccine should prevent

o   Transmitting the disease to others

o   The need for the child to stay out of LCCAP Early Learning Programs during disease outbreaks

· My health care provider, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention have all strongly recommended that the vaccine(s) be given

Nevertheless, I have decided to decline the flu vaccine recommended for my child.

 I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others that my child might come in contact with.  I know that I may re-address this issue with my healthcare provider at any time, and that I may change my mind and accept vaccination for my child any time in the future.

 I acknowledge that I have read this document in its entirety and fully understand it.