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BCHU
Body
School Vaccination Consent 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
select
Male
Female
Non-binary/third Gender
Other
Prefer not to say
Unknown
Ontario Health Card #
e.g..0000-000-000-XX
School
select
Grade
select
Parent/Guardian Name
Daytime Phone
e.g. 000-000-0000
Next
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
No
(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
No
(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
No
(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)
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Step 3. Your child's health
Does your child have a weakened immune system due to illness or medication?
Yes
No
If yes, explain
Has your child ever had a reaction to a vaccine?
Yes
No
If yes, explain
Does your child have a history of fainting or seizures?
Yes
No
If yes, explain
Does your child have any allergies (e.g. yeast, alum, latex etc)?
Yes
No
If yes, explain
Does your child have a serious medical condition?
Yes
No
If yes, explain
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Step 4. Consent for vaccination
I have read the vaccine information sent by the Brant County Health Unit through my child’s school.
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
Yes
No
Human papillomavirus (HPV) vaccine
Yes
No
Hepatitis B vaccine
Yes
No
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.
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