Consent form for schools

  COVID 19

Vaccination consent form for children and young people

The COVID-19 vaccine is being offered to your child. Your child will receive their first COVID-19 vaccine and you may be notified about the second dose later. The leaflet sent with this form includes more information about the vaccines currently in use. Please discuss the vaccination with your child, then complete this form before it is due. Information about the vaccinations will be put on your child’s health records.

 

Child’s full name (first name and surname):

Date of birth:

Home address:

Daytime contact telephone number for parent/carer:

NHS number (if known):

Ethnicity:

School (if relevant):

Year group/class:

GP name and address:

 

Consent for COVID-19 vaccination (Please complete one box only)

I want my child to receive the COVID-19 vaccination

I do not want my child to have the COVID-19 vaccine

Name:

Name:

Signature:

Parent/Guardian

Signature:

Parent/Guardian

Date:

Date:

If after discussion, you and your child decide that you do not want them to have the vaccine,  it would be helpful if you would give the reasons for this on the back of this form.

 

Ask for the What to expect after your COVID-19 vacccination leaflet at gov.uk/government/publications/covid-19-vaccination-resoures-for-children-and-young-people. It will tell you about the side effectsand how to report them to the Coronavirus Yellow card scheme at coronaviris-yellowcard.mhra.gov.uk

 

OFFICE USE ONLY

Date of COVID-19 vaccination

Site of injection

(please circle)

Batch number/ expiry date

Immuniser

(please  print)

Where administered

( hub, PCN, GP etc)

First

 

L arm

R arm

 

 

 

Second

 

L arm

R arm

 

 

 

© Crown copyright2021. Product code: COV2021ERCU18 1p 3M SEP 2021 (APS). Public Health England gateway number 2021484.

To order more copies of this leaflet please go to Health Publications website and use Product code: COV2021ERCU18 1p 3M SEP 2021 (APS)