Consent form Grade 7

TETANUS, DIPHTHERIA AND PERTUSIS (Tdap) VACCINE
HUMAN PAPILLOMAVIRUS (HPV) VACCINE

PLEASE COMPLETE SECTIONS 1 AND 2

 

SECTION 1: STUDENT’S PERSONAL INFORMATION
Work or home

ALERT

SECTION 2: PARENT / GUARDIAN CONSENT

For the two vaccines, check YES or NO, sign and date.

Your signature will confirm the following:

  • I have read the information I was given on the Human Papillomavirus (HPV) and the Tetanus, Diphtheria and Pertussis (Tdap) vaccines.
  • I understand the benefits and possible reaction(s) for each vaccine and the risk of not getting immunized.

If you have any questions, please call your local Public Health office.

Tetanus, Diphtheria & Pertussis (Tdap) Vaccine – 1 dose
Human Papillomavirus (HPV) Vaccine – 2 doses

Please read this information before completing the consent form.

dcaT | VPH