Consent for Vaccines

Student's Name

Date:

Date of Birth

Age

Sex

Dear Parent/Guardian:
Our records show that you have a consent on file for your child to receive services offered by the Jefferson Parish Public School System School-Based Health Centers. One of the many services we offer is administering immunizations. We follow the guidelines set by the Centers for Disease Control and Prevention. We would like all of our students to be current in their immunizations. The school's records show that your child needs the following immunizations:

These vaccinations are required by the State of Louisiana for school attendance:

DTaP/Tdap/Td

MMR

Varicella (chicken pox):

MCV4

Polio

HBV

Hep A

If Varicella (chicken pox): Has your child had the chicken pox disease (i.e. rash)?

Yes No

The Centers for Disease Control and Prevention also recommends the following immunization(s) for your child:

Influenza

Gardasil (HPV)

MenB

No record on file. Please return a copy of his/her latest immunization records as soon as possible.

Please answer the questions below:

1. Is anyone in the household immunosuppressed? (Example: HIV positive, cancer drugs or radiation, daily steroid doses)

Yes No

2. Is the student allergic to Neomycin, Polymyxin, Streptomycin, Gentamicin, Thimerosal, Eggs, Yeast, Gelatin, or Latex?

Yes No

3. Has the student had an anaphylactic reaction to vaccinations before? (Example: stopped breathing, difficulty breathing, or turned blue around the mouth or fingernails.)

Yes No

4. Has the student received gamma globulin during the past 3 months?

Yes No

5. Has the student ever had Guillain-Barre syndrome (paralyzing illness)?

Yes No

6. Is the student pregnant or thinks she is pregnant?

Yes No

Please note the attached information sheets. We will need your signature on this consent form to complete this service for your child in the health center. If you have any questions or concerns, please feel free to call the clinic.

I permit the person named above to be given the recommended vaccine(s) checked. I am the parent or legal guardian of this person. I have been given a copy of the vaccine information statements attached to this form. I understand the benefits and risks of all vaccines.

Name of parent/legal guardian

Address:

Phone:

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

Signature of Parent or Legal Guardian:

Date:

Sign here for your child to receive vaccine(s)

Respectfully Yours,

RN School-Based Health Center

Your information will be encrypted.