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Elkhart County Government

forms@elkhartcounty.com

117 N. 2nd Street, Goshen, IN, 46526, US

574-535-6631

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How the school clinics work

  1. Complete all sections of School Clinic Sign Up and Consent form prior to the deadline listed for your school. Be sure to include your email address and valid contact information so the Elkhart County Health Department can contact you if we have any questions about your child’s form.
  2. You will receive an email at the email address listed confirming the date of your child’s school clinic, the vaccines your child will receive and any potential costs.
  3. You child will be vaccinated at the school.
  4. Contact Elkhart County Health Department (574-523-2127) or your school nurse if you have any questions.

 

Note: If you have private insurance, please have your policy number/member identification and group number ready before you begin filling out this form.

 

School Vaccination Clinics

Student Name

Gender

Date of Birth

Date Picker

Address

    I do not have access to email.

    Parent /Guardian Name (1)

    Parent/Guardian Name (2)

    Race

    Ethnicity

    School List

    What is your insurance plan type?

    Members Date of Birth

    Date Picker

    Member Gender

    Relationship to Member

    The following questions will help us determine which vaccines your child may receive. If you answer “yes” to any question, please explain in the space provided. Answering “yes” does not necessarily mean your child should not be vaccinated. It just means additional questions might be asked. If a question is not clear, please contact the Health Department to explain it.

    Does the child have allergies to medications, food, a vaccine component, or latex?

    Yes No

    Has the child had a serious reaction to a vaccine in the past?

    Yes No

    Has the child had a health problem with lung, heart, kidney, or metabolic disease (e.g. diabetes), asthma, or a blood disorder? Is he/​she on long-term aspirin therapy?

    Yes No

    Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?

    Yes No

    Has the person to be vaccinated ever had Guillian-Barre syndrome or any other neurological diseases?

    Yes No

    Has the child, a sibling, or a parent had a seizure or other nervous system problem?

    Yes No

    Does the child have cancer, leukemia, HIV/​AIDS, or any other immune system problem?

    Yes No

    In the past 3 months, has the child taken medications that weaken their immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatments?

    Yes No

    In the past year, has the child received a transfusion of blood or blood products, or been given immune (gamma) globulin or any antiviral drug?

    Yes No

    Is the child/​teen pregnant or is there a chance she could become pregnant in the next month?

    Yes No

    Has the child received vaccinations in the past 4 weeks?

    Yes No

    Consent for Services

    Click here to view vaccine information statements (VIS) 

    https://www.immunize.org/vis/

     

    CONSENT FOR SERVICES: I understand and consent to immunization services administered by the Elkhart County Health Department in the school setting. I consent to all CDC ACIP (Centers for Disease Control and Prevention Advisory Committee on Immunization Practices) recommended vaccines based on client’s age and immunization history provided by the school and CHIRP (Children and Hoosiers Immunization Registry Program) unless specifically declined on the attached refusal form. ACIP recommended vaccines may include DTaP/Tdap, Polio (IPV), Hepatitis B, MMR (measles, mumps, rubella), Varicella, Hepatitis A, Meningococcal ACWY, Meningococcal B, Human Papillomavirus, Influenza, COVID-19. I also consent to management of a medication reaction which may include but is not limited to diphenhydramine and/or epinephrine should my child have an immediate reaction.

     

    I wish to DECLINE the following CDC ACIP recommended vaccines:

    I have read the Centers for Disease Control and Prevention's (CDC) Vaccine Information Statements explaining the vaccine(s) and the disease(s) they prevent. I have had the opportunity to discuss these with a health care professional who answered all my questions regarding the recommended vaccine(s).

    I understand the following:

    - The purpose of and the need for the recommended vaccine(s)

    -The risks and benefits of the recommended vaccine(s)

    - If I/my child do(es) not receive the vaccine(s), the consequences may include:

    - contracting the illness the vaccine should prevent

    - transmitting the disease to others

    - the need for me/my child to stay out of work, daycare or school during disease outbreaks

    - The Elkhart County Health Department, the American Academy of Pediatrics, and the CDC have all strongly recommended that the vaccine(s) be given

    Nevertheless, I have decided to decline the vaccine(s) recommended for my/my child, as indicated above, by checking the appropriate box under the column titled "Declined."

    I know that failure to follow the recommendations about vaccination may endanger the health or life of me/my child and others that I/my child might come in contact with.

    I know that I may re-address this issue with my health care provider and/or the Elkhart County Health Department and that I may change my mind and accept vaccination for me/my child anytime in the future.

    Sign Here

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