School Immunization Parental Consent Form
Student Information
Student Name
Date of Birth
Grade
School Name
Parent/Guardian Information
Parent/Guardian Name
Relationship to Student
Contact Phone
Email Address
Immunization Consent
Immunizations to be administered
Known allergies or medical conditions
Additional information or instructions
I, the parent or guardian of the student named above, give consent for the administration of the immunizations specified.
Signature of Parent/Guardian
Date