CONSENT FORM FOR THE (PFIZER) VACCINATION

(PLEASE FILL THIS FORM IN CAPITAL LETTERS)

STUDENT’S NAME : Sandeep Subasinghe

………………………………………………………..

CLASS 8-E
: GRADE ………………….

PARENT’S NAME Jayamini Fernando

: ……………………………………………………….

PARENT’S NIC NO
807852345v
: ……………………………………………………….

TEL. NO 0112245875
: ……………………………………………………….

ADDRESS No 85/1 udammita jaela

: ……………………………………………………….

………………………………………………………..

………………………………………………………..

I wish to give my consent to give the vaccine to my son.

Thank you.

2022/01/07
…………………………….. ……………………………..

DATE PARENT’S SIGNATURE