9.30.26 Honokaa El Student FLU SHOT Vaccination Consent Form

The following questions will help us determine if your child may receive the Flu Shot (inactivate influenza vaccine). Please select YES or NO for each question.

Rows	YES	NO
Has your child ever had a serious allergic reaction to eggs or a component of any flu vaccine?
Has your child ever had a serious reaction to a previous dose of flu vaccine?
Has your child ever had Guillain-Barre Syndrome (a serious nervous system disorder)?

If you answered YES to any question, your child will NOT be able to receive the Flu Shot through the school vaccination program. Please talk to your child's primary care provider.

CONSENT FOR CHILD'S VACCINATION

I have received and read the Vaccine Information Statement for Influenza (Flu) Vaccine (Inactivated or Recombinant): What you need to know, dated 1/31/2025. I understand the risks and benets, and give consent to KTA Pharmacy and its authorized staff for my child, named at the top of this form, to receive the FLU SHOT and to share information regarding my child’s influenza vaccination with my child’s doctor and my child’s health insurance company. I understand that KTA Super Stores, its divisions and affiliates and their respective officers, directors, employees, agents and representatives are immune from civil liability under federal and state law for all claims for loss related to any known or unknown side effects and/or injuries, included but not limited to death, that my child may experience from this vaccine. In addition, I have received information regarding the Hawaii State Immunization System (HISIS).
Parent or Legal Guardian Name:

First NameLast Name
Parent or Legal Guardian Daytime Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Legal Guardian Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Legal Guardian Signature:
Date

MonthDayYear
Date
Date of Administration:

MonthDayYear
Date
Should be Empty:

Student FLU SHOT Vaccination Consent Form 2026-27