Powell County School Based Health

School Year 2026 - 2027

Informed Consent for Vaccines

I have read or had read to me information about the vaccines listed below. I have been given the Vaccine Information Statement(s), VIS, for the vaccines being administered. I had the chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine(s) to be administered and ask that the vaccine(s) selected (marked “X”) to be given to me or the patient. I also give permission to share my immunization record with facilities or institutions, which are required by law to have such records and with my other health care provider(s). I understand that my insurance will be billed for the visit and vaccine(s) given.

Select vaccine(s) being administered:

	Vaccine	VIS Date
	DTaP	05/17/07
	Hepatitis A	07/20/16
	Hepatitis B	07/20/16
	HPV	012/02/16
	MenACWY	03/31/16
	MenB	08/09/16
	MMR	04/20/12
	MMRV	05/21/10
	Polio	07/20/16
	Tdap	02/24/15

Student Information

School

First Name   Middle Name   Last Name
SSN   Birthdate

Parent / Guardian Information

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Clear Signature

Name Phone Signed