Are you completing the form for a student or an employee?
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STUDENT - I am completing the form for my child to receive a flu shot at school.
EMPLOYEE - I am completing the form as a school employee to receive a flu shot at school for myself.
STUDENT - I am completing the form for my child to receive a flu shot at school.
EMPLOYEE - I am completing the form as a school employee to receive a flu shot at school for myself.
To complete the form, have these items handy.
Child's name and address Child's school and grade (and homeroom teacher, if applicable) Child's date of birth Insurance card(s) used when the child receives a vaccine The county health department and your child's school have partnered to provide seasonal influenza (flu) vaccinations at your child's school. Why should my child be immunized against the flu? The flu vaccine is recommended for everyone 6 months of age and older. An influenza vaccine is the best way to reduce the risk of getting sick with influenza and developing any of the potentially complications that can result. influenza vaccination also can reduce the spread of influenza to others. This service to the students and staff is being provided to decrease the impact of seasonal flu in our communities and to decrease school absenteeism. How can I get more information? If, after you review the Vaccine Information Statement, you have questions, you may contact the health department and ask to speak to a nurse. You may also want to visit the CDC's influenza web site at http://www.cdc.gov/flu/ . Your child's health care provider also can answer your questions about the influenza virus. Is there a charge? Will my child's insurance pay for this immunization? If your child is covered by insurance, including TennCare and private insurance, the health department will file a claim with the insurance plan and receive reimbursement directly from the insurance plan. If your child is uninsured, there is a cost up to $20. If you would like to be considered for a sliding scale reduced fee, please contact the health department to provide your family size and income. When will immunizations be available? Who will provide the immunizations? Clinics will begin as soon as the vaccine arrives at the health department (usually middle- to late-fall). You will be notified about the date flu vaccine will be given once it is scheduled. Health department nurses will vaccinate children and school staff using the injectable (shot). Consent Form If you would like for your child to receive flu vaccine, please complete this entire. Be sure to sign the form as this will be your permission for your student to receive the vaccine. A separate consent form is required for each child who will receive the vaccine. If later you change your mind and do not wish for your child to receive flu vaccine at the school, please notify the health department before the date shots will be given at the school.
I have reviewed the flu Vaccine Information Statement.
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Yes
No
Bledsoe Bradley Franklin Grundy Marion McMinn Meigs Polk Rhea Sequatchie
Bledsoe Bradley Franklin Grundy Marion McMinn Meigs Polk Rhea Sequatchie
School
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Bledsoe County Board of Education Bledsoe County Middle School Bledsoe County High School Cecil B. Rigsby Elementary School Mary V. Wheeler Elementary School Pikeville Elementary School Other, not listed
School
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Bledsoe County Board of Education Bledsoe County Middle School Bledsoe County High School Cecil B. Rigsby Elementary School Mary V. Wheeler Elementary School Pikeville Elementary School Other, not listed
School
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Arnold Elementary School Black Fox Elementary School Blythe Bower Elementary School Bradley Central High School Bradley County Virtual School Candies Creek Elementary School Charleston Elementary School Cleveland Middle School Cleveland High School Donald P. Yates Primary School Ernest L. Ross Elementary School GOAL Academy Hopewell Elementary School Lake Forest Middle School Mayfield Elementary School Michigan Avenue Elementary School North Lee Elementary School Oak Grove Elementary School Ocoee Middle School Park View Elementary School Prospect Elementary School Stuart Elementary School Taylor Elementary School Valley View Elementary School Walker Valley High School Waterville Community Elementary School Other, not listed
School
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Arnold Elementary School Black Fox Elementary School Blythe Bower Elementary School Bradley Central High School Bradley County Virtual School Candies Creek Elementary School Charleston Elementary School Cleveland Middle School Cleveland High School Donald P. Yates Primary School Ernest L. Ross Elementary School GOAL Academy Hopewell Elementary School Lake Forest Middle School Mayfield Elementary School Michigan Avenue Elementary School North Lee Elementary School Oak Grove Elementary School Ocoee Middle School Park View Elementary School Prospect Elementary School Stuart Elementary School Taylor Elementary School Valley View Elementary School Walker Valley High School Waterville Community Elementary School Other, not listed
School
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Broadview Elementary School Clark Memorial School Cowan Elementary School Decherd Elementary School Franklin County High School Huntland School North Lake Elementary North Middle School Rock Creek School Sewanee Elementary School South Middle School Other, not listed
School
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Broadview Elementary School Clark Memorial School Cowan Elementary School Decherd Elementary School Franklin County High School Huntland School North Lake Elementary North Middle School Rock Creek School Sewanee Elementary School South Middle School Other, not listed
School
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Grundy County High School North Elementary School Pelham Elementary School Swiss Memorial Elementary School Tracy City Elementary School Other, not listed
School
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Grundy County High North Elementary Pelham Elementary Swiss Memorial Elementary Tracy City Elementary Other, not listed
School
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Jasper Elementary School Jasper Middle School Marion County High School Monteagle Elementary School Richard Hardy Memorial School South Pittsburg Elementary School South Pittsburg Academy South Pittsburg High School Whitwell Elementary School Whitwell Middle School Whitwell High School Other, not listed
School
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Jasper Elementary School Jasper Middle School Marion County High School Monteagle Elementary School Richard Hardy Memorial School South Pittsburg Elementary School South Pittsburg Academy South Pittsburg High School Whitwell Elementary School Whitwell Middle School Whitwell High School Other, not listed
School
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Athens City Intermediate School Athens City Middle School Athens City Primary School Calhoun Elementary School Central High School of McMinn County Central Office - Athens City Schools E. K. Baker Elementary School Englewood Elementary School Etowah City Elementary School McMinn County Career Tech Center McMinn County High School Mountain View Elementary School Niota Elementary School Riceville Elementary School Rogers Creek Elementary School Other, not listed
School
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Athens City Intermediate School Athens City Middle School Athens City Primary School Calhoun Elementary School Central High School of McMinn County Central Office - Athens City Schools E. K. Baker Elementary School Englewood Elementary School Etowah City Elementary School McMinn County Career Tech Center McMinn County High School Mountain View Elementary School Niota Elementary School Riceville Elementary School Rogers Creek Elementary School Other, not listed
School
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Meigs County High School Meigs Middle School Meigs North Elementary School Meigs South Elementary School Other, not listed
School
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Meigs County High School Meigs Middle School Meigs North Elementary School Meigs South Elementary School Other, not listed
School
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Benton Elementary School Chilhowee Middle School Copper Basin Elementary School Copper Basin High School South Polk Elementary School Polk County High School Polk Innovative Learning Academy Other, not listed
School
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Benton Elementary School Chilhowee Middle School Copper Basin Elementary School Copper Basin High School South Polk Elementary School Polk County High School Polk Innovative Learning Academy Other, not listed
School
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Calvary Baptist School Dayton City School Fraizer Elementary School Graysville Elementary School Rhea Central Elementary School Rhea County Alternative School Rhea County High School Rhea County Middle School Spring City Christian Academy Spring City Elementary School Spring City Middle School Other, not listed
School
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Calvary Baptist School Dayton City School Fraizer Elementary School Graysville Elementary School Rhea Central Elementary School Rhea County Alternative School Rhea County High School Rhea County Middle School Spring City Christian Academy Spring City Elementary School Spring City Middle School Other, not listed
School
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Griffith Elementary School Sequatchie County Middle School Sequatchie County High School Other, not listed
School
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Griffith Elementary School Sequatchie County Middle School Sequatchie County High School Other, not listed
Name of school
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Pre-K Kindergarten 1 2 3 4 5 6 7 8 9 10 11 12
Homeroom Teacher (if assigned)
* First Name
*La st Name
MI:
* Date of birth
* Address
* City
* State
* Zip Code
Child's Social Security Number
* Parent's Primary Phone
Parent's Other Phone
*Sex
* Race
* Ethnicity: Hispanic
* First Name
*La st Name
MI:
* Date of birth
* Address
* City
* State
* Zip Code
Social Security Number
* Phone
Cell Phone
*Sex
* Race
* Ethnicity: Hispanic
* Parent/Guardian First Name:
* Parent/Guardian Last Name:
MI:
Daytime Phone:
Does the child have allergies to medications, food, a vaccine component, or latex?
Is the child sick today?
Has the child had a serious reaction to a vaccine in the past?
Is the child pregnant or is there a chance she could become pregnant during the next month?
Has the child had a brain or other nervous system problem?
Has the child ever felt dizzy or faint before, during, or after a shot?
Is the child anxious about getting a shot?
Has the child ever had an influenza vaccine?
Has the child received at least 2 influenza vaccine doses prior to July 1, 2025?
Do you have allergies to medications, food, a vaccine component, or latex? Are you sick today? Have you had a serious reaction to a vaccine in the past? Are you pregnant or is there a chance you could become pregnant during the next month? Have you had a brain or other nervous system problem?
Have you ever felt dizzy or faint before, during, or after a shot?
Are you anxious about getting a shot?
I consent for this child to receive flu vaccine at school.
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Yes No
I consent to receive flu vaccine.
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Yes No
SIGNATURE REQUIRED
Tap or click 'Add Signature' below.
*Parent/Guardian Signature * Date
SIGNATURE REQUIRED
Tap or click 'Add Signature' below.
What type of insurance coverage does the child have?
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What type of insurance coverage do you have?
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You may receive a bill in the mail for up to $20. If you want to provide your family size and income, your charges may be adjusted on a sliding scale.
Family size Monthly income
You may receive a bill in the mail for up to $20. If you want to provide your family size and income, your charges may be adjusted on a sliding scale.
Family size Monthly income
TennCare Information * TennCare Carrier* TennCare ID#
Private Insurance Information * Name of Insurance Plan* Does insurance cover vaccines? * Policy Number* Group Number * Name of Subscriber* Birth Date of Subscriber * Address To File Claims (back of card) Insurance Card Front Insurance Card Back
TennCare Information * TennCare Carrier* TennCare ID#
Private Insurance Information * Name of Insurance Plan* Does insurance cover vaccines? * Policy Number* Group Number * Name of Subscriber* Birth Date of Subscriber * Address To File Claims (back of card) Insurance Card Front Insurance Card Back
Last Name
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Last Name
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First Name
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First Name
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M-D-Y
M-D-Y
View equation View equation Address
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Address
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State
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State
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Male
Female
Male
Female
Phone
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Phone
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Ethnicity: Hispanic
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Yes
No
Ethnicity: Hispanic
* must provide value
Yes
No
Parent/Guardian last name
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Parent/Guardian First Name
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Parent/Guardian Middle Initial
Allergies
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* Please list the allergies.
Allergies
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* Please list the allergies.
Reaction
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Reaction
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* If currently pregnant, what is the estimated due date?
* If currently pregnant, what is the estimated due date?
brain
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brain
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dizzy
* must provide value
dizzy
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* Was this a specific shot or all shots?
* Was this a specific shot or all shots?
Request for Administration of Vaccines for the above named recipient: I received information about vaccines required for school or requested and special precautions on the Vaccine Information Sheets prior to my child receiving vaccines and on the day of vaccination. I have had an opportunity to ask questions regarding the vaccines and understand the risks and benefits.
I request and voluntarily consent that the vaccines agreed to below be given to the person above of whom I am parent or legal guardian and acknowledge that no guarantees have been made concerning the vaccine's success. I hereby release Tennessee Department of Health, their affiliates, employees, directors, and officers from any and all liability arising from any accident, act of omission or commission, which arises during vaccination.
Request for Administration of Vaccines for the above named recipient: I received information about vaccines required for school or requested and special precautions on the Vaccine Information Sheets prior to my child receiving vaccines and on the day of vaccination. I have had an opportunity to ask questions regarding the vaccines and understand the risks and benefits.
I request and voluntarily consent that the vaccines agreed to below be given to the person above of whom I am parent or legal guardian and acknowledge that no guarantees have been made concerning the vaccine's success. I hereby release Tennessee Department of Health, their affiliates, employees, directors, and officers from any and all liability arising from any accident, act of omission or commission, which arises during vaccination.
I understand that this document will be given to and retained by the Tennessee Department of Health. I give permission for my child's school to retain a copy if needed. I acknowledge that I have been given the Department of Health's Notice of Privacy Practices. I understand that immunizations/vaccines my child receive will be sent to the State Immunization Registry and the Tennessee Immunization Program. I acknowledge that I have been given access to the Department of Health's Notice of Privacy Practices . I give consent to bill TennCare or Private insurance for the service provided. This Consent Form is valid for administration of vaccinations for twelve (12) months. I understand that I should report any changes of the above information to the health department prior to vaccination.
I understand that this document will be given to and retained by the Tennessee Department of Health. I give permission for my child's school to retain a copy if needed. I acknowledge that I have been given the Department of Health's Notice of Privacy Practices. I understand that immunizations/vaccines my child receive will be sent to the State Immunization Registry and the Tennessee Immunization Program. I acknowledge that I have been given access to the Department of Health's Notice of Privacy Practices . I give consent to bill TennCare or Private insurance for the service provided. This Consent Form is valid for administration of vaccinations for twelve (12) months. I understand that I should report any changes of the above information to the health department prior to vaccination.
Parent/Guardian Signature
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Today M-D-Y
Today M-D-Y
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
TennCare
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BlueCare/TennCare Select
United Healthcare
Wellpoint
BlueCare/TennCare Select
United Healthcare
Wellpoint
TennCare
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BlueCare/TennCare Select
United Healthcare
Wellpoint
BlueCare/TennCare Select
United Healthcare
Wellpoint
TennCare ID#
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TennCare ID#
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Private Insurance Name
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Private Insurance Name
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Vaccine Coverage
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Yes
No
Vaccine Coverage
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Yes
No
Group Number
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Group Number
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DOB of Subscriber
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M-D-Y
DOB of Subscriber
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M-D-Y
Now Y-M-D H:M:S
Now Y-M-D H:M:S
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