Florida School Immunization Consent Form

Submit the completed form to your child's school administration office. You may also send it via email to the school's health coordinator or fax it to the provided fax number. If submitting a physical copy, ensure it is delivered to the designated school official or health office. For online submissions, upload the completed form to the school's online portal if available.

School vaccination clinics are generally scheduled at the beginning of the school year and mid-year. Specific dates will be communicated by the respective school administration.

The purpose of the School Immunization Consent Form is to gather essential information about the student and obtain parental or guardian consent for immunizations. This form ensures that students are up-to-date with necessary vaccines to comply with Florida state immunization requirements. Accurate completion of this form helps schools and healthcare providers manage and track student immunization records efficiently.

• 1. Student's Legal Last Name: Field to enter the legal last name of the student.
• 2. First Name: Field to enter the first name of the student.
• 3. Date of Birth: Field to enter the student's date of birth in MM/DD/YYYY format.
• 4. Mailing Address: Field to enter the mailing address of the student.
• 5. Daytime Phone: Field to enter a contact phone number for daytime hours.
• 6. Medical Insurance: Field to provide medical insurance information.
• 7. Sex: Field to select the student's sex (Male, Female, Other).
• 8. Parent/Guardian Last Name: Field to enter the last name of the parent or guardian.
• 9. Parent/Guardian First Name: Field to enter the first name of the parent or guardian.
• 10. City: Field to enter the city of residence.
• 11. State: Field to enter the state of residence (pre-filled as Florida).
• 12. Zip: Field to enter the ZIP code of the mailing address.
• 13. Student ID#: Field to enter the student's identification number.
• 14. Grade: Field to enter the student's grade level.
• 15. Medical Insurance ID#: Field to enter the medical insurance identification number.
• 16. School: Field to enter the name of the student's school.
• 17. Medical Group#: Field to enter the medical group number associated with the insurance.
• 18. Race: Field to select the student's race.
• 19. Ethnicity: Field to select the student's ethnicity.
• 20. Vaccines Initials: Fields to select and initial the vaccines for consent, including TDAP, HPV, MEN ACWY, and Hepatitis A.
• 21. Medical Screening Questions: Fields to answer medical screening questions related to allergies and previous vaccine reactions.
• 22. Consent Signature: Field for the parent or guardian to sign and give consent for vaccination.
• 23. Print Name: Field for the parent or guardian to print their name.
• 24. Clinic Use Only: Fields for clinic use only, including vaccine, lot number, site/route, and vaccinator information.

Failing to submit this form may result in your child not receiving necessary immunizations.

• Missed Immunizations: Your child may miss out on important vaccines needed for their health and school compliance.
• Non-Compliance: Your child may not meet the state immunization requirements for school attendance, which could result in exclusion from school activities.

• 1. School Enrollment: When enrolling your child in school to ensure they meet immunization requirements.
• 2. Vaccine Updates: When updating your child's vaccine records with new immunizations.
• 3. Health Check-Ups: During routine health check-ups to keep your child's immunization records current.
• 4. School Health Programs: For participation in school health programs that require up-to-date immunizations.
• 5. Documenting Immunizations: To document and track the immunizations your child has received.