Grade 7 Immunization Consent Form "*" indicates required fields This consent form is to be completed for all students entering Grade 7 in September, indicating either a yes or no response for each of the three immunizations offered. Student InformationFirst Name* Last Name* Ontario Health Card #*Only enter the 10 numbers from your Health Card. If you do not have a Health Card, enter 1111.School*Aberarder Central SchoolBosanquet Central Public SchoolBridgeview Public SchoolBrigden SchoolBright's Grove Public SchoolBrooke Central SchoolCathcart Boulevard Public SchoolColonel Cameron Public SchoolConfederation Central SchoolDawn-Euphemia Public SchoolEast Lambton Elementary SchoolÉcole Élémentaire Catholique Saint-Francois XavierÉcole Élémentaire Franco-JeunesseErrol Road Public SchoolErrol Village Public SchoolGrand Bend Public SchoolGregory A Hogan Catholic SchoolHanna Memorial Public SchoolHigh Park Public SchoolHillcrest Public SchoolHoly Rosary Catholic SchoolHoly Trinity Catholic SchoolJohn Knox Christian SchoolKing George VI Public SchoolKinnwood Central Public SchoolLakeroad Public SchoolLambton Centennial Public SchoolLansdowne Public SchoolLondon Road SchoolMooretown-Courtright Public SchoolP.E. McGibbon Public SchoolPlympton-Wyoming Public SchoolQueen Elizabeth II School - PetroliaQueen Elizabeth II School - SarniaRiverview Central SchoolRosedale Public SchoolSacred Heart Catholic School - SarniaSacred Heart Catholic School -Port LambtonSarnia Christian SchoolSir John Moore Community SchoolSt Anne Catholic SchoolSt John Fisher Catholic SchoolSt Joseph Catholic SchoolSt Matthew Catholic SchoolSt Michael Catholic SchoolSt Peter Canisius Catholic SchoolSt Philip Catholic SchoolDate of Birth* MM slash DD slash YYYY Address Street Address City Province / Territory Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Grade* 7 8 Parent/Legal Guardian InformationParent/Legal Guardian First Name* Parent/Legal Guardian Last Name* Relationship to Student*ParentLegal GuardianPrimary Phone*Secondary Phone (optional)Consent for ImmunizationI have read the related vaccine information sheet. I understand the expected benefits and possible risks and side-effects of the vaccines. I understand the possible risks to my child if not vaccinated. I had the opportunity to have my questions answered by Lambton Public Health. This consent is valid for two (2) years. I understand that I can withdraw my consent at any time. I understand that my child may receive up to three (3) needles in one day.Meningococcal ACYW-135 *Required for school attendanceI authorize Lambton Public Health to administer 1 dose of meningococcal ACYW-135 vaccine to my child.* Yes No Hepatitis BI authorize Lambton Public Health to administer 2 doses of hepatitis B vaccine to my child.* Yes No Human Papillomavirus (HPV)I authorize Lambton Public Health to administer 2 doses of human papillomavirus (HPV) vaccine to my child.* Yes No If your child has been previously immunized with any of the vaccines mentioned, please update or view your child’s immunization record online at LambtonPublicHealth.ca/reporting-immunizations. If you need assistance, contact us by email at immunization@county-lambton.on.ca or call 519-383-8331. Student Health HistoryIs your child allergic to yeast, aluminum, latex, diphtheria toxoid protein, other?* Yes No Additional Details about your Child's Allergies*Has your child ever had a reaction to a vaccine?* Yes No Additional Details about any serious reaction to vaccination that your child has experienced*Does your child have a history of fainting or seizures?* Yes No Additional Details about your child's history of fainting or seizures*Does your child have any medical condition(s)?* Yes No Additional Details about any medical conditions or diagnosis that your child may be experiencing*Does your child have a weak immune system or is your child taking a medication that increases the risk of infection? (e.g. corticosteroids)* Yes No ** We recommend that you visit your health care provider or specialist to receive these vaccines at the appropriate schedule. If your provider cannot administer these vaccines, we require a schedule from your child’s health care provider prior to immunizing your child at school. Please contact us at 519-383-8331 to provide this schedule for approval by our Medical Officer of Health. ** Additional Details about any illnesses or medications that could weaken your child's immune system*Does your child require accommodations?* Yes No Additional Details about your child's accommodation needs*Acknowledgements Consent to Collection, Use and Disclosure of Personal Health Information: Lambton Public Health is collecting your personal health information for the purpose of providing immunization services to your child. The information you submit will be used for planning of vaccination clinics. The contact information you provide will be used if follow-up is required. Your personal health information is collected, used and disclosed for these purposes under the Health Protection and Promotion Act and in accordance with the Personal Health Information Protection Act, 2004.Acknowledged On 12/10/2024Acknowledgement* I acknowledge the above to be true Consent to Receive E-mail ConfirmationBy providing your email address you are consenting to receive an email from Lambton Public Health confirming receipt of this consent form. Please understand if emailing personal health information that email software and/or services are not guaranteed to be completely secure, and although all precautions possible are taken by Lambton Public Health, emailed information could be inappropriately accessed by others. Email Personal health information on this form is collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c.h.7. Information is used to administer the Lambton Public Health Vaccine Preventable Diseases Program, including maintaining immunization records for students. If you have any questions about the collection and maintenance of this information, call Lambton Public Health at 519-383-8331 or toll-free 1-800-667-1839. For more information contact Lambton Public Health at 519-383-8331