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SCHOOL-BASED IMMMUNIZATION EXERCISE | 104 S. EYDER AVE., PHILLIPS, WI 54555
I have been given a copy and have read, or have had explained to me, information about influenza and the influenza vaccine to be received. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the vaccine be given to the person named above for whom I am authorized to make this request. I understand that if I am a BadgerCare recipient I cannot be charged an administration fee or asked for any type of donation for the administration of the influenza vaccine. Information on this form will be used to document receipt of the influenza vaccine in the Wisconsin Immunization Registry (WIR). My signature below authorizes my child to receive the initial dose of the influenza vaccine and if needed, a booster dose.
I wish to submit this influenza administration form by electronic means. By signing this permission form, I certify, that my answers are correct and complete to the best of my knowledge. I understand the questions and statements on this permission form. I understand that an electronic signature has the same legal effects and be enforced the same way as a written signature.
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