Authorization and Consent to Immunize

Delegation of Authority to Consent to Immunizations (a parent may given written authority to another adult [18 years and older] to consent to immunize their child in the parent's absence).

Please complete the following form and have it turned in during the child's immunization appointment.

I, Parent/Guardian*, authorize and consent for Adult Bringing Child* to bring my child, Child's Name* , to the Platte County Health Department to receive their immunization.

I agree for my child to receive the following immunizations and verify that I have read the Vaccine Information Statements (VIS) for each vaccine they are to receive as well as the Emergency Use Authorization Form (EUA) for the COVID-19 Vaccine.

Vaccine(s) Consent to Administer

Signature of Parent or Legal Guardian

Print Name

Relationship to Child

Parent, Legal Guardian, etc.

Date of Signature

Date

Authorize & Consent to Immunize