Consent form Grade 9

MENINGOCOCCAL (Men A, C, Y, W-135) VACCINE
VARICELLA (chickenpox) 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 Meningococcal and the Varicella 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.

Meningococcal (A, C, Y, W-135) Vaccine – 1 dose
Varicella (chickenpox) Vaccine – 1 dose

Please read this information before completing the consent form.

Meningitis | Varicella