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2024-2025 STUDENT Influenza Vaccination Form

Register Now for Your Student to Receive a Flu Shot

Medical practitioners from Bolivar Medical Center will be on campus Thursday, November 7th to administer flu shots to our students (ages 3+) and teachers.  Flu shots will be $25 each and will not be billed through your medical insurance.  If you would like your child to receive a flu shot at school, please complete the information below.  

Please complete a SEPARATE FORM for EACH STUDENT.

** The DEADLINE to REGISTER is 3:00 Friday, November 1st **

PAYMENT 

AFTER your student receives the vaccine, the COST of this vaccine will be charged to your student's FACTS account with an incidental invoice.  You may already have your FACTS account set up to pay incidental invoices using a preferred payment method.  If so, the payment for this invoice will automatically process using your preferred payment method.  IF NOT, you will need to log into FACTS and pay this invoice or send money to the school for our business office to apply your payment in FACTS.  Any payment sent to the school should be clearly marked with the student's name and indicate it is for the flu shot.  Please direct any questions about billing to the school financial office.

Student Gender*
Answer Required
State*
Answer Required

Medical Information:  The following questions will help us determine if this student can receive the influenza vaccine.  Please choose YES or NO for each question.

1. Is this the FIRST time the student has EVER received a flu vaccine?*
Answer Required
2. Has the student received any vaccines in the last 4 weeks? If yes, please list.*
Answer Required
3. Has the student ever had a serious reaction to eggs?*
Answer Required
4. Has the student ever had a serious reaction to any influenza vaccine?*
Answer Required
5. a. Does the student have asthma or a wheezing condition?*
Answer Required
5. b. If yes, does the student use inhalers and/or breathing treatments?
Answer Required
6. Is the student on long-term asprin-containing therapy or taking asprin every day?*
Answer Required
7. Does this student have any significant or chronic (long-term) health conditions?*
(for example diabetes, sickle cell disease, heart conditions, seizures, etc.)
Answer Required
8. Does this student have a weak immune system or use medications such as steroids or cancer drugs?*
(for example HIV, cancer, etc.)
Answer Required
9. Has the student ever had Guillain-Barre Syndrome (GBS)?*
Answer Required

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.