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School Vaccine Form Offered by Public Health
5th-grade TDAP vaccine Form
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* Indicates required question
Students First Name:
*
Your answer
Student Last Name:
*
Your answer
Student Date of Birth
*
Your answer
Student mailing Address:
*
Your answer
Student insurance ( Copy required)
*
Medicaid
Private insurance ( example Blue Cross, United Healthcare)
Cash/Check cost $ 20.00
Parent First and Last Name:
*
Your answer
Parent Date of Birth:
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Your answer
Parent phone number:
*
Your answer
Do you have any allergies?
*
Yes: please list
No
Please check the option you are choosing:
*
I would like my child to receive the TDAP at school.
I will receive the TDAP at Public Health.
I am opting out of vaccines, Please see school nurse for instructions
By completing and submitting this form, you consent that your child to receive the vaccine at school on April 18, 2023. In addition, you are permitting KCCDPHE to submit a claim to your insurance company on your behave for reimbursement.
*
Yes I give consent for my child to receive vaccine at school
No I do not give permission for my child to receive vaccine at school
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