Consent for Influenza Vaccine

2018-2019

Influenza (flu) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness. Serious outcomes of flu infection can result in hospitalization or even death.
Students at the Academy live in close quarters and the flu can spread quickly. An annual flu vaccine is the best way to reduce your child's chances at getting the seasonal flu and spreading it to others. The Center for Disease Control (CDC) recommends that everyone 6 months of age and older receive an annual flu vaccine. We are making a thimerasol-free influenza (flu) vaccine available to all students for a nominal charge.

This charge (approximately $20) will be billed to your student’s account.  Please complete the form below and submit online, by mail, or by fax (336.217.7132) to the Health Center by JULY 15, 2018.  It is important that we receive this consent by the date listed above since we must know how much vaccine to order.  If your form is received after this date your student’s name will be placed on a waiting list to receive the vaccine. We encourage all of our students and faculty to be immunized against the influenza viruses (flu).

INFLUENZA CONSENT FORM

Influenza is a contagious infection caused by a virus.  An injection of the flu vaccine will not give anyone the flu, since the vaccine is made from killed viruses.  Side effects from the vaccine are generally mild and occur infrequently.  Side effects may consist of tenderness at the injection site, fever, chills, headaches, or muscular aches and may last up to forty-eight hours.

If the student is pregnant or suspected of being pregnant, she is not eligible to receive the vaccine without written consent from a physician. 

I verify that the student named below has not had a severe reaction to eggs or to the influenza vaccine. Additionally I verify that my child has not had Guillian Bare’ Syndrome within six weeks of receiving the flu vaccine previously.

I understand that if my son/daughter has a serious reaction other than soreness at the injection site, she/he will be examined by a physician that has been designated by the AmericanHebrewAcademyHealthCenter staff.

I have read the above information and will contact the AmericanHebrewAcademyHealthCenter staff with any questions.  I understand the benefits and risks of the influenza vaccine as described.  I request that the vaccine be given to my daughter/son. By having signed this form, I agree that the AmericanHebrewAcademy, its trustees and employees will not be liable for unknown and unforeseen conditions arising from my son/daughter receiving the influenza vaccine.