Consent to Participate Form

- RETAIN A COPY OF THIS FORM IN THE MEDICAL RECORD -

REGISTRANT INFORMATION

Registrant Name:

Date of Birth:

Country of Birth:

Name of Primary Health Care Provider:

PARENT/GUARDIAN INFORMATION (if NJIIS Registrant is a minor)

Name:

Address:

City, State, Zip Code:

Relationship to Registrant:

I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history.

I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools, licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.

I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number listed above.

There is no cost to participate in this program.

Yes, I would like to participate in this program.

No, I do not want to participate in this program.

Signature of Registrant (or Parent/Guardian, IF Registrant under 18 Years of Age)

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Date:

Name of NJIIS Enrollment Site:

Registry ID Number:

Medical Record Number:

- RETAIN A COPY OF THIS FORM IN THE MEDICAL RECORD -

Your information will be encrypted.