School name : ______________________________ clinic date: ________________________________

Adolescent School Immunization Clinic Parental Consent Form
School Name : ______________________________ Clinic Date: ________________________________
In order for your child to obtain the adolescent vaccinations during this school based clinic, you must
1. Complete this form, 2. Provide previous vaccination records, and 3. Sign & Date the bottom of form.
A. INFORMATION ABOUT PERSON RECEIVING VACCINE (PLEASE PRINT)
Student’s Name
Last ________________________ First _________________ Student’s Birth Date_________________________________ Age __________________ Parent/Guardian Name Last ________________________ First _________________
Student’s Address __________________________________ City __________________ B. VACCINE ELIGIBILITY SCREENING (PLEASE CHECK APPROPRIATE BOX)
o Medicaid (Package A) A child, 0 thru 18 years of age, who has Medicaid Package A or Hoosier Healthwise. The parent does
o Medicaid (Package C) A child, 0 thru 18 years of age, who has Medicaid Package C. The parent pays a premium for the
o American Indian/Alaskan Native A child, 0 thru 18 years of age, who identifies as an American Indian or Alaskan Native,
o No Health Insurance A child, 0 thru 18 years of age, who does not have health insurance.
o Limited Health Insurance A child, 0 thru 18 years of age, who has health insurance, but the health insurance does not pay for
vaccine coverage or the parent does not know if the insurance pays for vaccine coverage.
o Insured A child, 0 thru 18 years of age, who has health insurance which provides coverage for vaccines.
C. VACCINE HEALTH SCREENING (CIRCLE YES OR NO)
Please answer al questions about the student who wil be receiving the vaccine(s). Answers will determine whether the
student can be vaccinated at this time. If you respond ‘Yes’ to any of the questions, please explain in the space provided.
Yes No 1. Does the student have any al ergies to medication, foods, or any vaccines? Yes No 2. Has the student had a serious reaction to a vaccine in the past?Yes No 3. Has the student had a health problem with asthma, lung disease, heart disease, kidney disease, metabolic disease (i.e. diabetes), or a blood disorder? Yes No 4. Has the student had a seizure, brain or other nervous system problem, including Guil ain-Barré Yes No 5. Does the student have cancer, leukemia, AIDS, active tuberculosis or any other immune system problem?Yes No 6. Has the student taken cortisone, prednisone, other steroids or anticancer drugs or had radiation Yes No 7. Has the student received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug in the past year? Yes No 8. Is the student pregnant or is there a chance she could become pregnant during the next month?Yes No 9. Has the student received vaccinations in the past four (4) weeks?Please explain any ‘Yes’ responses._____________________________________________________________________________ _____________________________________________________________________________________________________________ D. CONSENT TO VACCINATE
I have been given a copy and I have read the information in the Vaccine Information Statement(s) for the Meningococcal,
Tetanus, Diphtheria, acel ular Pertussis and/or Varicel a (Chickenpox) vaccines. I understand the benefits and risks of
each of the indicated vaccines and ask the fol owing vaccines be given to my child on the scheduled school clinic date
(check al the apply):
 Tetanus, Diphtheria, acel ular Pertussis (Tdap) I give permission to the Indiana State Department of Health and/or their designees to vaccinate the student named on this form. Signature of Parent/Guardian ______________________________________

Source: http://www.barr.k12.in.us/Health/2010_School_Based_Consent_Form_For_Website.pdf