VISD Student COVID Vaccination Pre-Registration Form

COVID-19 Vaccine Registration Form
Please use this form to register for Covid-19 vaccinations to be administered at Vashon High School and McMurry Middle School. A Parent or Guardian must complete and electronically sign this form for students under the age of 18. Registrations are accepted for students 12 and older in anticipation of Emergency Use Authorization (EUA) for Pfizer-BioNTech COVID-19 vaccine for youth aged 12-15. The EUA has been in effect already for youth aged 16 and 17.
I attest that I am the parent or guardian of the student for whom I am completing this form.I attest that I am 18 years of age or older

INSURANCE INFORMATION
PLEASE PROVIDE YOUR PRESCRIPTION INSURANCE COVERAGE INFORMATION - If you do not have insurance please leave this blank. Vaccinations are FREE to all - patients will NOT be charged for administration.
You may take a picture of your insurance card and upload it here instead of manually entering information if you wish. Click browse file to select or take your photo.
Cancelof
RX BIN#
Insurance ID
Insurance Group #
Prescription Insurance PCN#
* Please provide if on card. Not all plans use this number
MEDICARE ID#
IF ON MEDICARE PLEASE SUPPLY YOUR MEDICARE # ON RED/WHITE/BLUE CARD (NOT SOCIAL SECURITY NUMBER)

Have you had a positive test for Covid-19 in the past 90 days?*
YesNo
If you have tested positive previously, on what date was that positive test?
MonthDayYear
You may type the date (format mm-dd-yyyy) instead of using the calendarselector.
Have you ever received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for Covid-19?*
YesNo
If you received antibody therapy on what date was the last therapy?
MonthDayYear
You may type the date (format mm-dd-yyyy) instead of using the calendarselector.

Thank you for your honesty and respect for others. We continue to get a good steady supply from the State and are excited that Vashon is asking for it. We look forward to serving you in the future. You may now close the window or browser if you wish. Have a great evening!
Current Covid Vaccines are only authorized for use in patients that are at least 16 years of age and being reviewed for patients 12-15. Due to being under 12 years of age we will not be able to adminster COVID vaccine to this patient at this time. Studies are currently underway evaluating safety in the Pfizer vaccine and we expect some news regarding use in younger populations in the coming months. You may close this page at this time or click back if you feel you have reached this notice in error.

Students who participate in the vaccination clinic at Vashon High School or McMurry Middle School will be vaccinated with the Pfizer-BioNTech vaccine. This vaccine requires two doses with a recommended wait time of 21 days between doses. Please read the information on this page and sign in the text box below. A parent/guardian has to sign for students younger than 18 years old.
Due to your history of anaphylaxis, Vashon Pharmacy, the MRC and our team of doctors would advise that you receive this vaccine in a clinical setting. Should you experience an anaphylatic reaction, we advise you be at a location that can administer more immediate care for you should this problem arise. Thank you for your interest in our vaccine site. You may submit this form now or simply close the window to exit.
Which Cohort are you part of? (*dates are subject to change*)
High School - Cohort A - Monday May 17* - AMHigh School - Cohort B - Thursday May 20* - AMHigh School - I am not part of Cohort A or B because I am not a Vashon Island School District student - I may come either morning to Vashon High School.Middle School - Cohort A - Monday May 17th* - PMMiddle School - Cohort B - Thursday May 20* - PMMiddle School - I am not part of Cohort A or B because I am not a Vashon Island School District student - I may come either afternoon to McMurray Middle School.
Due to recent CDC recommendations and studies based on outcomes reviewed in patients with a history of COVID-19, it is recommended that you delay vaccination. Once 90 days have passed since your COVID-19 infection, we look forward to proceeding with the vaccination process. If you have questions regarding this particular situation we are happy to discuss them with you.
You may select an appointment at any time based on the slots available. Please read our Patient Arrival Instructions sheet provided in the email following submission so that you are prepared.
Vaccine Appointment: Dose #1 (more appts may be available in April)
Pfizer sequence gap is 21 days: Please select a date for your second vaccine dose that is 21 days AFTER your first dose. Specifically, after the date below:
28 Days Later Pair
MonthDayYear
Date
Hour MinutesAM/PM Option
Appointment #1 Pair
MonthDayYear
Date
Hour MinutesAM/PM Option
Vaccine Appointment: Dose #2 (available dates in May as well click down arrow next to month to navigate to April)
Appointment #2 Pair
MonthDayYear
Date
Hour MinutesAM/PM Option
VaccineTag
Dose2ReminderEmail
MonthDayYear
Date
• I certify that I am: (a) the patient and atleast 18 years of age; (b) the legal guardian of the patient and confirm thatthe patient is at least 16 years of age; or (c) authorized to consent forvaccination for the patient named above. Further, I hereby give my consent to VashonPharmacy or its agents to administer the COVID-19 vaccine.
• I understand that this product has not been approved orlicensed by FDA, but has been authorized for emergency use by FDA, under an EUAto prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 16 yearsof age and older; and the emergency use of this product is only authorized forthe duration of the declaration that circumstances exist justifying theauthorization of emergency use of the medical product under Section 564(b)(1)of the FD&C Act unless the declaration is terminated or authorization revokedsooner.
• I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization FactSheet on the COVID-19 vaccine I have elected to receive. I also acknowledgethat I have had a chance to ask questions and that such questions were answeredto my satisfaction.
• I acknowledge that I have been advised to remain near thevaccination location for approximately 15 minutes (or more in specific cases)after administration for observation. If I experience a severe reaction, I willcall 9-1-1 or go to the nearest hospital.
• On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the Vashon Pharmacy, the WashingtonDepartment of Health (DOH), and their staff, agents, successors, divisions,affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, inconnection with, or in any way related to the administration of the vaccine listed above.
• I acknowledge that:(a) I understand the purposes/benefits of Washington’s immunization registry and (b) Vashon Pharmacy will include my personal immunization information in the IIS registry and my personal immunization information will be shared with theCenters for Disease Control (CDC) or other federal agencies.
• I further authorize Vashon Pharmacy or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to Vashon Pharmacy or its agents with respect to the above requested items and services.
• I acknowledge receipt of the Notice of Privacy Rights.

By clicking signing below I accept these terms and conditions.
- I understand that Vashon Pharmacy may use my Name, Date of Birth, Medical Conditions and Allergy information in this form to help schedule, administer and treat me in the event of a medical emergency. The use of this information will be limited to only individuals directly working at the vaccination site or within Vashon Pharmacy as it relates to my care. This form information will not be shared in any way or form without my consent in the future. The record of this vaccination will be sent to Local and State authorities as required. *
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COVID-19 Vaccine Registration Form

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INSURANCE INFORMATION

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