Consent For Grade 6 Immunizations Form
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1
2Consent for Grade 6
ImmunizationsSection
USE A PEN AND PRINT CLEARLY TO COMPLETE FORM AND RETURN IT TO THE SCHOOL. THANK YOU.
:
H
B, M
C
ACYW-135
V
(
)
.
ALL STUDENTS
EPATITIS
ENINGOCOCCAL
ONJUGATE
AND
ARICELLA
CHICKENPOX
VACCINES
:
FEMALES
H
ONLY
UMAN PAPILLOMAVIRUS VACCINE
Section 1: Student’s Personal Information (Parent / guardian must complete)
Last Name
First Name
Birthdate (YYYY/MM/DD)
Male Female
Health Card Number
Mailing Address, Town, Postal Code
School
Parent/Guardian Name (Print)
Your Relationship to this Student
Evening Phone
Teacher
(
)
Day Phone
Cell Phone
Text only?
Email Address (optional)
Yes
(
)
(
)
Section 2: Student’s Health Checklist (Parent / guardian must complete)
1) Has this student ever had a serious or life-threatening or allergic reaction to a vaccine or a vaccine component?
No Yes If yes, describe: _________________________________________________________________
2) Does this student have any medical conditions or severe drug allergies?
No Yes If yes, describe: _________________________________________________________________
3) Has this student received a blood transfusion, a blood product or an immune globulin in the past year?
No Yes If yes, provide product(s) and date(s): _______________________________________________
4) Is this student taking medication (e.g. prednisone) or has a disease or is receiving medical treatment which lowers their
immunity (e.g. cancer or HIV)?
No Yes If yes, describe: ________________________________________
5) Has this student received any vaccines in the past 3 months?
No Yes If yes, specify vaccine(s): __________________________________________________________
6) Has this student ever received a vaccine outside of Saskatchewan; in different community than they currently live in;
from a doctor or other healthcare provider; or that has been paid for (e.g., Twinrix®)?
No Yes If yes, specify vaccine(s), date(s) and location if known: ________________________________________
Section 3: Consent for Immunization (Parent / guardian must complete)
I understand the information in the immunization fact sheet(s) provided to me. My questions have been
answered to my complete satisfaction. I understand the proven benefits and possible reactions for these
vaccines, and the possible risks to this student if they are not immunized. If this student has an adverse reaction
to these vaccines, medical attention will be sought and public health informed. Unless cancelled in writing, this
consent is valid for the time period needed to give all required doses of the vaccines noted below.
Please be aware that parents/guardians/individuals are responsible to contact the health clinic to get missed
vaccines if they are needed in the future (e.g., for post-secondary education, work, travel, etc.).
F
,
/
Y
N
,
.
OR EVERY VACCINE IN THE BOXES BELOW
A PARENT
GUARDIAN MUST CHECK
ES OR
O
AND SIGN AND DATE
I
I
CONSENT FOR THIS STUDENT TO BE IMMUNIZED WITH
CONSENT FOR THIS STUDENT TO BE IMMUNIZED WITH
B
:
-135
: Yes
Yes
No
No
HEPATITIS
VACCINE
MENINGOCOCCAL CONJUGATE ACYW
VACCINE
YY/MM/DD
Signature ________________ Date ___________
Signature ___________________ Date _____________
YY/MM/DD
I
I
FEMALE
CONSENT FOR THIS STUDENT TO BE IMMUNIZED WITH
CONSENT FOR THIS
STUDENT TO BE IMMUNIZED WITH
:
: Yes
Yes
No
No
THE VARICELLA VACCINE
THE HUMAN PAPILLOMAVIRUS VACCINE SERIES
Signature ________________ Date __________
YY/MM/DD
YY/MM/DD
Signature ____________________ Date ______________
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