Documente Academic
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Home address:
Ethnicity:
School:
Year group/class:
Name
Name
Signature
Parent/Guardian
Signature
Parent/Guardian
Date
Date
If, after discussion, you and your child decide that you do not want them to have the vaccine, it would be helpful if
you would give the reasons for this on the back of this form (and return to the school).
Any side effects following the MenACWY vaccination should be reported to the school nurse or your GP
PLEASE COMPLETE THE FOLLOWING SECTION TO ENABLE US TO UPDATE OUR RECORDS
Does your child have any serious medical conditions or had a reaction to previous immunisations? Yes / No
If yes please describe...
Does your child have any allergies? Yes / No
If yes please describe..
Are they currently taking any medication? Yes/No
If yes please describe..
Thank you for completing this form. Please return in the envelope provided as soon as possible.
OFFICE USE ONLY
Date of MenACWY
vaccination
Site of injection
(please circle)
L arm
R arm
Batch number/
expiry date
Immuniser
(please print)
Where administered
(school, college, GP etc)