*VACCINATION AUTHORIZATION(Required.)

Yes, I give permission for my child to receive the MENINGOCOCCAL CONJUGATE VACCINE (MCV) as indicated at school. I have read the Vaccine Information Sheet for MCV and have had my questions answered.

INFORMATION ABOUT YOUR CHILD

Child’s Legal Name:

Date of Birth:

Age:

Sex:

Race:

Ethnicity (Hispanic or Not Hispanic):

School:

Grade:

Teacher:

CONTACT INFORMATION

Home Address:

City:

State:

ZIP:

Phone Number:

Mother's Name:

Father's Name:

Guardian (if under 18):

Relationship to Child:

Emergency Contact Name:

Emergency Contact Phone:

ALLERGIES

This child has allergies to:

*Has this child had a serious reaction to a vaccine in the past?(Required.)

Yes

No

*Has this child, a sibling, or a parent ever had a seizure?(Required.)

Yes

No

*Has this child had a brain or other nervous system problem?(Required.)

Yes

No