School Vaccination Consent Book Form

Child Info
Vaccination History
Child Health
Consent
Confirmation

Office Use Only

Step 1. Your child's information

Client's First name

Client's Last name

Date Of Birth (mm/dd/yyyy)

Gender

Ontario Health Card #

e.g..0000-000-000-XX

School

Grade

Parent/Guardian Name

Daytime Phone

e.g. 000-000-0000

Step 2. Your child's vaccination history

Please indicate if your child has previously received any of the following vaccines.

Meningococcal-ACYW-135 vaccine

Yes

(ex. Menactra, Menveo, or Nimenrix)

Please note this is NOT the same as the meningitis vaccination routinely administered at 1yr.

Date of Dose 1: (mm/dd/yyyy)

Human papillomavirus (HPV) vaccine

Yes

(ex. Gardasil, Gardasil-9, or Cervarix)

Date of Dose 1: (mm/dd/yyyy)

Date of Dose 2: (mm/dd/yyyy)

Date of Dose 3: (mm/dd/yyyy)

Hepatitis B vaccine

Yes

(ex. Twinrix, Twinrix Jr, Recombivax-HB, Engerix-B, or INFANRIX-hexa)

Date of Dose 1: (mm/dd/yyyy)

Date of Dose 2: (mm/dd/yyyy)

Date of Dose 3: (mm/dd/yyyy)

Step 4. Consent for vaccination

I have read and understand the Vaccine Fact Sheets for Meningitis, Hepatitis B and HPV. I understand the expected benefits and possible risks and side effects of the vaccines. I understand the possible risks to my child if not vaccinated. I have had the opportunity to have my questions answered by the Brant County Health Unit. I understand that I can withdraw my consent at any time. I understand that my child may receive up to three needles in one day.

I give consent to the Brant County Health Unit to administer the following vaccines to my child:

(You must select “Yes” or “No” for each vaccine listed)

Meningococcal vaccine (Men C-ACYW-135)

Yes

Human papillomavirus (HPV) vaccine

Yes

Please note, HPV is a two dose vaccine series with a recommended interval of 6 months between doses. We will be returning to your child’s school in the spring to provide the second dose. Selecting “Yes” provides consent to both doses. Consent can be withdrawn at any time.

Hepatitis B vaccine

Yes

Please note, Hepatitis B is a two dose vaccine series with a recommended interval of 6 months between doses. We will be returning to your child’s school in the spring to provide the second dose. Selecting “Yes” provides consent to both doses. Consent can be withdrawn at any time.

Note: The Brant County Health Unit will review your child’s vaccination history (see Step 2) and vaccinate only if your child requires it.

I have read, understand and agree to the Brant County Health Unit’s Privacy Statement regarding the collection of information.

Confirmation message

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School Vaccination Consent Form