Electronic Signature Agreement

Please list the Legal First and Last Name along with the Date of Birth for each child you are signing for (as listed in MIWAIV online learning platform):

By selecting the “I accept” button below, you hereby execute this Agreement electronically. You acknowledge and agree that your electronic signature constitutes your legal binding signature and is the full legal equivalent of your handwritten signature. By selecting “I accept” through any device, mechanism, or method, you expressly consent to be bound by all terms, conditions, and obligations set forth herein. You further acknowledge that your electronic signature (hereinafter, the “E-Signature”) shall be deemed valid and enforceable to the same extent as a signature affixed in ink to a physical document.

You additionally agree that no certification authority, digital certificate, or other third party authentication is required to validate your E signature, and that the absence of such certification or verification shall in no way diminish or impair the enforceability of your E signature or any agreement entered into between you and the Tuscola County Health Department. You affirm that you are duly authorized to execute this Agreement on your own behalf or on behalf of the individual you are legally permitted to represent.

Furthermore, by affixing your E-Signature below, you attest that you have viewed the vaccine education modules available within the MIWAIV platform. You also authorize Tuscola County Health Department staff to enter or record your name, as Parent/Legal Guardian, into the Michigan Care Improvement Registry (MCIR) as a valid signature for purposes of completing the non-medical exemption (waiver) form required for school or childcare enrollment.

By selecting the “I Do Not Accept” button below, you decline to provide an electronic signature. In such case, your electronic signature will not be accepted, and you will be required to contact our office to schedule an in-person appointment with a nurse to physically sign the non-medical exemption (waiver) form.

Tuscola County Health Department
Immunizations Program
Phone: 989-673-8116
 

Please select your option as to the terms stated above:

SelectI AgreeI Do Not Agree

Parent/Legal Guardian Name    

Email Address

A copy of this signed Agreement will be emailed to you once completed.

Parent/Legal Guardian Signature