Permission Slip

Please Print Clearly NAME: _____________________________ ADDRESS: __________________________ PHONE: ____________________________ DOB/AGE: __________________________ GRADE: ____________________________

SEX MALE____ FEMALE___ RACE CAUCASIAN_______ 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, 1 DOSE_______ 2 DOSES_______

WHEN/YEAR________

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!