New Jersey Department of HealthVaccine Preventable Disease ProgramP.O. Box 369, Trenton, NJ 08625-0369609-826-4860 (Fax 609-826-4866)www.njiis.nj.gov
NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)CONSENT TO PARTICIPATE
Name
*
First Name
Last Name
Date Of Birth
*
PARENT/GUARDIAN INFORMATION (if NJIIS Registrant is a minor)
First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Primary Health Care Provide
Country of Birth
*
Relationship to Registran
*
I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purposeof this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/mychild's immunization history.I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools,licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by NewJersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department,or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone numberlisted above.There is no cost to participate in this program.
*
Yes, I would like to participate in this program.
No, I do not want to participate in this program.
Signature of Registrant (or Parent/Guardian, IF Registrant under 18 Years of Age)
Date
-
Month
-
Day
Year
Date
Name of NJIIS Enrollment Site
Please Read the Vaccine Information on next page.
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