Here is a translatable version of the Covid-19 Vaccination Consent Form (children aged 12-15) which has been sent home for parents.   This translatable version is for your information only.  Please ensure you fill in and return the printed English version of the form.  Thank you.  School Office

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COVID 19

Vaccination consent form for children and young people

The COVID-19 vaccine is being offered to your child. Your child will receive their first COVID-19 vaccine and you may be notified about the second dose later. The leaflet sent with this form includes more information about the vaccines currently in use. Please discuss the vaccination with your child, then complete this form before it is due. Information about the vaccinations will be put on your child’s health records.

 

Child’s full name (first name and surname):	Date of birth:
Home address:	Daytime contact telephone number for parent/carer:
NHS number (if known):	Ethnicity:
School (if relevant):	Year group/class:
GP name and address:

 

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Consent for COVID-19 vaccination (Please complete one box only)

I want my child to receive the COVID-19 vaccination		I do not want my child to have the COVID-19 vaccine
Name:		Name:
Signature: Parent/Guardian		Signature: Parent/Guardian
Date:		Date:

If after discussion, you and your child decide that you do not want them to have the vaccine, it would be helpful if you would give the reasons for this on the back of this form.

Ask for the What to expect after your COVID-19 vaccination leaflet at gov.uk/government/publications/ covid-19-vaccination-resources-for-children-and-young-people. It will tell you about the side effects and how to report them to the Yellowcard scheme at yellowcard.mhra.gov.uk.

If after discussion, you and your child decide that you do not want them to have the vaccine, it would be helpful if you would give the reasons for this on the back of this form.

OFFICE USE ONLY
Date of COVID-19 vaccination		Site of injection (please circle)		Batch number/ expiry date	Immuniser (please  print)	Where administered ( hub, PCN, GP etc)
First		L arm	R arm
Second		L arm	R arm