Summer Registration Form

Please complete the form below for your school or community-based clinic. * Indicates a REQUIRED field.

Select the School your child currently attends *

Select the School Clinic in the district your child currently attends * 

Student Legal Name *  

Student Preferred Name   

Current Age *  
Middle School clinics are for ages 11-14 • High School Clinics are for ages 16-18

Name *  

Relationship to Student * (only the custodial parent may provide consent. If another guardian is providing consent, guardian paperwork is required. Guardianship paperwork may be emailed to imms@clayhealth.com or faxed to 816-595-4390).

Cell    Home    Work    Other   

Cell    Home    Work    Other   

A custodial parent or legal guardian is required to bring the child to the school clinic if the child is seventeen or under. If someone other than the custodial parent or legal guardian is bringing the child to the clinic please provide their name and relationship to the child. This person must be over the age of 18 and provide a photo ID upon check-in. Completing this section provides consent for this person to bring the child for immunizations.

Parent/Guardian Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form you understand and agree that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
 

 

Which vaccines will your student be receiving at the School Clinic? Check all applicable. *

If the child has private insurance or insurance that does not cover Vaccines providing this information regardless of coverage is required. Failure to do so may result in delaying the registration process and/or your child not being able to be seen at this clinic. *

Select “I agree” to give permission for the Clay County Public Health Center to vaccinate the student named on this form. I attest that If I had questions, I contacted the Clay County Public Health Center at 816-595-4355 and my questions were answered. I fully understand the benefits and risks of each of the indicated and ask that the vaccines selected above be given to my child on the scheduled school clinic date.
* I Agree

Vaccine Information Statements
Select “I agree” to acknowledge that you were provided vaccine information statements.
* I Agree

Privacy Policy
Select “I agree” to acknowledge that you were provided with Clay County Public Health Center's privacy notice.
* I Agree

Personal Financial Responsibility
By signing this form, and in return for the services rendered by Clay County Public Health Center (CCPHC), I am personally responsible for all fees not paid by any third party on my behalf.
* I Agree

Select "I agree" to give permission to Clay County Public Health Center to vaccinate the student named on this form.
* I Agree

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form you understand and agree that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you may still be required to provide a traditional signature at a later date, and 4) by submitting this form you are approving CCPHC to send an automatic reply to the email address provided verifying the student’s participation in this clinic.

If under the age of 18 please have parent or guardian sign.

 

By submitting this form you are approving CCPHC to send an automatic reply to the email address provided verifying the student’s participation in this clinic and/or you are approving CCPHC to contact you via phone call or text if additional information is needed.

Student Screening Form

Please answer questions about the person receiving the vaccine(s)

The following questions will help us determine which vaccines your student may be given. If you answer yes to any question, it does not necessarily mean they should not be vaccinated. It means additional questions must be asked. If a question is not clear, please call 816-595-4355.

 1. Do you have allergies to medications, food, a vaccine component, or latex? *  
     Yes    No   

 2. Have you had a serious reaction to a vaccine in the past? *  
     Yes    No   

 3. Do you have a health problem with lung, heart, kidney, or metabolic disease, i.e., diabetes, asthma, or a blood disorder? Are you on long term aspirin therapy? *  
     Yes    No   

 4. Have you ever had a seizure, or had a brain or other nervous system problem? *  
     Yes    No   

 5. Does the student have or live with someone who has cancer, leukemia, HIV/AIDS, or immune system problems? *  
     Yes    No   

 6. In the past 3 months, have you taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or had radiation treatments? *  
     Yes    No   

 7. In the past year, have you received a blood transfusion or blood products, or have been given a medicine called immune (gamma) globulin or an antiviral drug? *  
     Yes    No   

 8. Have you received any vaccinations in the past 4 weeks? *  
     Yes    No   

 9. Are you nursing, pregnant, or is there a chance you could become pregnant during the next month?   
     Yes    No     N/A   

10. To be answered the day of clinic   Are you sick today?
     Yes    No