Upcoming School Based Vaccination Clinics

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· I am choosing to have my child vaccinated with the Covid-19 vaccination. I know I have the option to refuse the vaccine. I ask that the vaccine be given to my child, as named above for whom I can make this request. I was provided the (Fact Sheet for Vaccine Recipients and Caregivers) for this vaccine: https://www.fda.gov/media/153717/download. The fact sheet has information about side effects and adverse reactions. I read or had read to me the information provided about the COVID-19 vaccine. 

· I know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. I know it is not a fully licensed FDA vaccine. I had the chance to ask questions that were answered to my satisfaction. I now know about the vaccine, alternatives, benefits, and risks, to the extent they are known and unknown at this time. 

· I know that my child must stay in the vaccine area and will be monitored by a licensed health care provider for 15 minutes. If you child has a known history of anaphylactic (allergy) reaction to previous vaccination, we recommend that you have your child vaccinated at a healthcare facility. We do have emergency anaphylactic medications (epinephrine) to administer in the even to an allergic reaction.

· I know that if my child has a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over their body or dizziness and weakness that I should call 9-1-1 or go to the nearest hospital. I know I can call my health care provider if my child has any side effects that bother me or do not go away. In the event of an allergic reaction, epinephrine would be administered and emergency care activated as indicated.

· I know I should report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or https://vaers.hhs.gov/reportevent.html. 

· I know that with all vaccines there is no promise I will become immune (not get the virus) or that I will not have side effects.

Disclosure of Records: I understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information as described in its Notice of Privacy Practices. 

· I am choosing to have my child vaccinated with the Influenza vaccination. I know I have the option to refuse the vaccine. I ask that the vaccine be given to my child, as named above for whom I can make this request. I was provided the (Fact Sheet for Vaccine Recipients and Caregivers) for this vaccinehttps: www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf The fact sheet has information about side effects and adverse reactions. I read or had read to me the information provided about the Influenza vaccine. 

· I know that my child must stay in the vaccine area and will be monitored by a licensed health care provider for 15 minutes. If you child has a known history of anaphylactic (allergy) reaction to previous vaccination, we recommend that you have your child vaccinated at a healthcare facility. We do have emergency anaphylactic medications (epinephrine) to administer in the even to an allergic reaction.

· I know that if my child has a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over their body or dizziness and weakness that I should call 9-1-1 or go to the nearest hospital. I know I can call my health care provider if my child has any side effects that bother me or do not go away. In the event of an allergic reaction, epinephrine would be administered and emergency care activated as indicated.

· I know I should report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or https://vaers.hhs.gov/reportevent.html. 

· I know that with all vaccines there is no promise I will become immune (not get the virus) or that I will not have side effects.

Disclosure of Records: I understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information as described in its Notice of Privacy Practices.