Consent to Vaccinate:

CONSENT FOR STUDENT TO RECEIVE INFLUENZA VACCINE:

By submitting this form, I give permission for the student named above to receive the influenza vaccine. I acknowledge that the student and medical information provided in this form are correct. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the influenza vaccine that will be given to the student whom I am authorized to represent. I understand that participation and receipt of the influenza vaccine through this program is completely voluntary. By submitting this form, I give permission for the student listed above to receive the injectible influenza vaccine. If this form is not filled in completely and submitted the student will not be vaccinated at school. I understand that the $25 cost for this vaccine will be charged to my Bayou Academy FACTS account.

If you have any questions regarding the flu shot, you may contact Ann Nowell at 662-846-2525.

2024-2025 STUDENT Influenza Vaccination Form