School Flu Immunization 2026 - Permission Form

INFORMATION ABOUT YOUR CHILD

Child’s Name:

Date of Birth:

Age:

Sex:

Race:

Ethnicity (Hispanic or non-Hispanic):

School:

Grade:

Teacher:

CONTACT INFORMATION

Home Address:

City:

State:

Zip:

Home Phone:

Parent/Guardian Name:

Relationship to Child:

Emergency Contact Name:

Emergency Contact Phone:

Preferred language:

English

Spanish

Other (please specify)

*ALLERGIES(Required.)

Yes

Has this child ever had a serious reaction to influenza vaccine?

Yes

Has this child ever had Guillain-Barre syndrome?

Yes

*VACCINATION AUTHORIZATION & ACKNOWLEDGEMENT OF VIS

Check all that are true and sign below:
(Required.)

Yes, I give permission for my child to receive the flu vaccine indicated at school.

I have read the Vaccine Information Sheet (VIS) for flu vaccine and have had my questions answered.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Transylvania Public Health’s Notice of Privacy Practices is available at this link. Your signature below acknowledges that we have given you a copy of our Privacy Notice, which explains how your health information will be handled in various situations. We must try to have you sign this form on your first date of service with us.

Check all that are true and sign below:

I have received the Transylvania County’s Privacy Notice.

I have been given a chance to discuss my concerns and questions about the privacy of my health information.

*PATIENT SIGNATURE (Parent/Guardian Signature if patient under 18)(Required.)

Signature

Date

HEALTH INFORMATION EXCHANGE NOTIFICATION

Transylvania Public Health participates in the NC HealthConnex health information exchange. Your information will be automatically included in this secure system after each visit. If you prefer not to participate, you can complete the Patient Opt-Out form and send it to the NC HIEA business office. Forms are available on the NC HIEA website (nchealthconnex.gov) and in our lobby.

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