Please Print Clearly

NAME: _____________________________ SEX

ADDRESS: __________________________ MALE____ FEMALE___
PHONE: ____________________________ RACE
DOB/AGE: __________________________ CAUCASIAN_______
GRADE: ____________________________ AFRICAN
AMERICAN_______
HISPANIC________
ASIAN _______
OTHER_______

UNDER 19 YRS. OF AGE

CIRCLE ONE
MEDICAID YES NO
PRIVATE INS/HMO YES NO PAYS 100% FOR IMMUNIZATIONS YES NO

I give the Fairfield County Health Department Nurse permission to administer the Flu vaccine to my child at
Richard Winn Academy.
X_____________________________________ (PARENT/GUARDIAN SIGNATURE)

I do not give the Fairfield County Health Department Nurse permission to administer the Flu vaccine to my
child at Richard Winn Academy.
X_____________________________________ (PARENT/GUARDIAN SIGNATURE)

I have read the Flu VACCINE INFORMATION SHEET (VIS) and have no questions.
X____________________________________ (PARENT/GUARDIAN SIGNATURE)

My child is not allergic to EGGS OR ANY OF THE CONTENTS OF THE FLU VACCINE.
X_____________________________________ (PARENT/GUARDIAN SIGNATURE)

My child has had a Flu shot before, WHEN/YEAR________

1 DOSE_______ 2 DOSES_______

If your child is under the age of 9 years and this is his/her 1st Flu shot, he/she will need a second dose in
30 days (1 month). Please contact the Fairfield County Health Department at 803-635-6481 for an
appointment or see your Private Medical Doctor.

**We invite and encourage parents of younger children to accompany his/her child during
vaccination. Getting a Flu shot is the best way to prevent the Flu!