Summer Registration Form
Please complete the form below for your school or community-based clinic.
*
Indicates a
REQUIRED
field.
Student Information
Select the School your child currently attends
*
Antioch Middle School
Discovery Middle School
Excelsior Springs High School
Excelsior Springs Middle School
Heritage Middle School
Kearney High School
Kearney Middle School
Liberty Academy
Liberty High School
Liberty Middle School
Liberty North High School
Maple Park Middle School
New Mark Middle School
North Kansas City High School
Northgate Middle School
Oak Park High School
Smithville High School
Smithville Middle School
South Valley Middle School
Staley High School
Winnetonka High School
Select the School Clinic in the district your child currently attends
*
North Kansas City Public Schools Clinic
Liberty Public Schools Clinic
Smithville Public Schools Clinic
Kearney Public Schools Clinic
Excelsior Springs Public Schools Clinic
Student Legal Name
*
Student Preferred Name
Date of Birth
*
Current Age
*
Middle School clinics are for ages 11-14 • High School Clinics are for ages 16-18
Race
*
Declined
Alaska Native
American Indian
Asian
Asian Indian
Black or African American
Caucasian
Filipino
Guamanian or Chamorro
Japanese
Korean
Native Hawaiian
Other Pacific Islander
Other Race
Vietnamese
White
Ethnicity
*
Declined
Hispanic/Latino
Not Hispanic/Latino
Gender
*
Male
Female
Declined
Preferred Language
*
Parent / Guardian Information
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).
Custodial/Biological Parent
Step-Parent
Guardian
Self/Student if age 18 and older
Other
Phone
*
Cell
Home
Work
Other
Alternate Phone
Cell
Home
Work
Other
Email Address
*
Address
*
City
*
State
*
Zip
*
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.
Name
Relationship
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.
Vaccines
Which vaccines will your student be receiving at the School Clinic? Check all applicable.
*
Tdap (Adacel®) -
Required
for Middle School ONLY
Tdap vaccine
protects against tetanus, diphtheria, and pertussis (whooping cough). Tetanus infection causes painful stiffening of the muscles and can lead to serious health problems including being unable to open the mouth, having trouble swallowing and breathing, or death. Diphtheria infection can lead to difficulty breathing, heart failure, paralysis, or death. Pertussis can cause uncontrollable, violent coughing that makes it hard to breathe, eat, or drink. In teens and adults, pertussis can cause weight loss, loss of bladder control, passing out, and rib fractures from severe coughing.
Meningococcal/ACWY (Menactra® or MenQuadfi®) -
Required
for Middle and High School
Meningococcal/ACWY
vaccine can help protect against meningococcal disease caused by serogroups A, C, W, and Y. Meningococcal disease can cause meningitis or infections of the blood. Even when treated, meningococcal disease kills 10% to 15% of the people infected. Of those that survive, 10% to 20% suffer disabilities including hearing loss, brain damage, kidney damage, loss of limbs, nervous system problems, or severe scars from skin grafts. A different meningococcal vaccine (offered below) can help protect against serogroup B.
HPV (Gardisil® 9) - Middle and High School –
Recommended
HPV vaccine
can prevent over 90% of the cancers caused by human papillomavirus. These cancers include cervical and vaginal cancers in people born female, penile cancers in people born male, anal and throat cancers. There are approximately 79 million Americans currently infected with HPV. (for ages 9 and older)
Men B (Bexsero® or Trumenba®) - High School ONLY –
Recommended
Meningococcal B
vaccine protects against meningitis, an infection of the lining of the brain and spinal cord. It is a different strain of meningococcal vaccine than that required for 8th & 12th grades. It is recommended for students ages 16 to 23 years as they are at increased risk of infection. It is required by some colleges. (for ages 16 and older)
Insurance Information
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.
*
Uninsured
Insurance does not cover Vaccines
Medicaid
Tricare
Private Insurance
DCN Number
*
Policy Holder First Name
*
Last Name
*
MI
Relationship of Policy Holder to Student
*
Policy Holder Date of Birth
*
Policy Holder Address
*
City
*
State
*
Zip
*
Policy Holder Gender
*
Declined
Female
Male
Unknown
Other
DOD No.
*
Social Security No.
*
Upload picture of front and back of Insurance Card (command-click to select multiple image files)
Insurance Company Name
*
Policy Number
*
Group Number
*
Name of Policy Holder
*
Last Name
*
MI
Relationship of Policy Holder to Student
*
Policy Holder Date of Birth
*
Policy Holder Address
*
City
*
State
*
Zip
*
Policy Holder Gender
*
Declined
Female
Male
Unknown
Other
Upload picture of front and back of Insurance Card (command-click to select multiple image files)
Authorization and Consent
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
Electronic Signature Agreement
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)
School
*
Student Name
*
Student DOB
*
Age
*
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
What is your student allergic to?
2. Have you had a serious reaction to a vaccine in the past?
*
Yes
No
Please explain which vaccine and details about the reaction
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
Please explain
4. Have you ever had a seizure, or had a brain or other nervous system problem?
*
Yes
No
Please explain
5. Does the student have or live with someone who has cancer, leukemia, HIV/AIDS, or immune system problems?
*
Yes
No
Please explain
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
Please explain
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
Please explain
8. Have you received any vaccinations in the past 4 weeks?
*
Yes
No
Please list all vaccines received
9. Are you nursing, pregnant, or is there a chance you could become pregnant during the next month?
Yes
No
N/A
If pregnant, how many weeks?
10. To be answered the day of clinic
Are you sick today?
Yes
No
Form completed by
*
Phone
*
Date
*