International Student Vaccination Consent Form
Student Information
Full Name
Date of Birth
Student ID
Passport Number
Email
Phone Number
Vaccination Details
Type of Vaccine
Dose Number
1st Dose
2nd Dose
Booster
Vaccination Date
Medical History
Known Allergies
Medical Conditions
Consent
I hereby give my consent to receive the vaccination as described above.
Student Signature
Date
For Official Use Only
Staff Name
Staff Signature
Date