School-based Vaccine Consent Form
Student Information
Full Name
Date of Birth
School Name
Grade/Class
Parent/Guardian Information
Parent/Guardian Name
Contact Number
Email Address
Medical Information
Allergies (if any)
Medical Conditions
Vaccine Consent
I give consent for my child to receive the vaccine at school.
I do NOT give consent for my child to receive the vaccine at school.
Parent/Guardian Signature
Date