Vaccination
Each Minor’s parents or legal guardian is required to fill out a consent form and be accompanied with the child in order to receive the vaccine.
( MINOR WHO WILL RECEIVE THE COVID-19 VACCINE )
First Name
Middle Name
Last Name
Date of Birth
Street Name
City
State
ZIP Code
I have read the Fact Sheet for Recipients and Caregivers: Emergency Use Authorization (EUA) of the Pfizer-BioNtech COVID-19 Vaccine to Prevent COVID-19 in Individuals 12 Years of Age and Older.
I have been made aware of the California Immunization Registry (CAIR) Notice to Patients and Parents. I understand the immunization data will be entered in the CAIR system and that I have the right to opt out of allowing the information to be shared with other organizations.
I give the County of Los Angeles and participating vaccination partners permission to contact me regarding important vaccine reminders and access to an electronic vaccination record.
If I have applicable health insurance coverage, I give permission for my insurance company to be billed for the costs of administering the vaccine. The government is paying for the vaccine itself, and I will not be billed for that portion of the cost of the immunization.
If the minor is 12 through 15 years of age, I acknowledge that the minor must be accompanied by a responsible adult. If a parent or legal guardian is unable to accompany the minor, I give consent for the responsible adult named below to accompany them instead. I understand that this adult must show photo ID. (Exception: If the minor is being vaccinated at school, consent is required; however, the school's guidance should be followed as to whether a parent/legal guardian or named adult needs to be present.)
Signature of legally authorized representative or independent minor
Date *
Name of the Legal Guardian or Parent *
Relationship to child *
Phone number (cell phone preferred) *
Will Parent be present or not? *
YesNo
For 12 through 15-year-olds who will not be accompanied by their parent or legal guardian only:
Name of responsible adult who will accompany the minor
If you check this box, you will be asked to attest to this at your vaccine appointment I am an emancipated or self-sufficient minor, or married or previously married.