INFLUENZA VACCINE 2016-2017 HEALTH SCREEN & PERMISSION FORM Full Name:
Date of Birth:
Street Address:
/ / Town/City:
Grade:
School Name: Age:
Gender: M
F
Zip Code:
Teacher:
Daytime Phone:
School Administrative Unit (District)
Is this person an American Indian or an Alaskan Native? yes
no
Is this person uninsured?
yes
no
Is this person insured by MaineCare (Medicaid)?
yes
no
yes
no
MaineCare ID #:______________________________ Private Insurance?
Name of Insurance Company: _______________________________________________________________ ID Number: ________________________________
Group Number: ____________________________
Subscriber Name: _____________________________ Subscriber Date of Birth: ______________________ Doctor’s Name:_______________________________________ Phone Number:________________________ Please answer the following questions about the person named above. Comments may be written on the back of this form. YES
NO
1) Does this person have a severe (life-threatening) allergy to eggs? 2) Has this person ever had a severe reaction to an influenza immunization in the past? 3) Has this person ever had Guillain-Barre Syndrome? If you answered “yes” to any questions 1-3, please see your healthcare provider for influenza vaccination
PERMISSION TO VACCINATE I was given a copy of the Influenza (Flu) Vaccine Information Statement, I have read this or had this explained to me and I understand the benefits and risks of the Influenza vaccine. I give permission for a record of this vaccination to be entered into the ImmPact Registry. I give permission for information to be used to bill MaineCare or private insurance for the cost of providing the vaccine I give my consent for this person to receive the most appropriate vaccine, as determined by the health care clinic staff . I give permission for the flu vaccine to be given to the person named above by signing below.
X________________________________________________________________ Date:____________________ Signature of parent or guardian if person to be vaccinated is a minor or Signature of adult to be vaccinated
Printed Name of Parent or Guardian:___________________________________________________________ FOR OFFICE USE ONLY:
Page 1 of 1. INFLUENZA VACCINE 2016-2017. HEALTH SCREEN & PERMISSION FORM. Full Name: Date of Birth: / /. Age: Gender: M F. Street Address: Town/City: Zip Code: Daytime Phone: Grade: Teacher: School Administrative Unit (District). Is this person an American Indian or an Alaskan Native? yes. no.
My child can handle the deep end of the indoor pool. â Sort of... My child would much rather hang out in the shallow end. â Nope!! Please don't allow my child to ...
The student listed above has the permission of the undersigned below to participate in events of and travel. with Eastside Baptist Church, Plant City, FL.
Special Instructions: All Beacon rules will be maintained. Group tents will be setup and at least one advisor per tent ... to receive emergency medical treatment.
5 Place of visit with nearest Railway Station : 6 Details of family members in whose respect. LTC is proposed to be claimed giving their. age (date of birth in case ...
Page 1 of 1. I give my child,. , permission to bring. their laptop to school on Sunday May 13th 2012 for Mr Jabrin's. language class. My child is completely ...
Students may be transported by staff in. staff vehicles, school issued vans, or school buses. Details of field trips ... permission to. participate in school field trips throughout the 2016-17 school year. Parent Signature: Date: ______. Page 1 of 1.
Loading⦠Whoops! There was a problem loading more pages. Whoops! There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. STEM permission slip.pdf. STEM permission
passed [taken] one time without seeking permission in order to earn a higher grade. ... repeats a course, credit toward the degree shall be allowed only once.
Please attach a copy of Administrator' Business Card (required if still in High School). All signatures must be authentic. Any forged signatures will result in the ...
Friends into Customers Full Online By #A#. Books detail ... Marketing. Godin argues that businesses can no longer rely solely on traditional forms of "interruption.
Page 1 of 2. HANDBOOK AGREEMENT/PERMISSIOM. PLEASE FILL OUT, SIGN, AND RETURN. (Signatures required on both sides of this form!) JHCA-E-2. HANDBOOK AGREEMENT. I,. , understand and agree to abide by the rules in the Athletic. (Student-Athlete Name). H
Page 1 of 1. Page 1 of 1. Parent Permission Slip.pdf. Parent Permission Slip.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Parent Permission Slip.pdf. Page 1 of 1.
White â FDLRS/Gateway Yellow â District Pink - Parent. Page 1 of 1. Permission for Screening.pdf. Permission for Screening.pdf. Open. Extract. Open with.
Page 1 of 3. PERMISSION TO RIDE. PARENT/GUARDIAN ATHLETIC RELEASE FORM AND WAIVER. SPORT: LEVEL: NAME OF ATHLETE: TRAVELING TO OR FROM: DESIGNATED DRIVER: ATHLETIC EVENT: DATE OF EVENT:______. I am the parent or guardian of. , a minor. I have. reques
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Edmodo ...