Online Immunization Consent Form - Northwestern Health Unit

Select your location/community *

Once you select your community, select the student’s school

Atikokan schools

St. Patrick’s school
Northern Lakes K-12 School

Barwick

Sturgeon Creek School

Balmertown school

Golden Learning Centre

Bergland

McCrosson-Tovell public school

Devlin school

Crossroads School

Dryden schools

Emo schools

Cornerstone Christian School
Donald Young School

Ear Falls school

Ear Falls Public School

Fort Frances schools

Fort Frances High School
J. W. Walker School
Robert Moore School
St. Mary School

Ignace schools

Ecole Immaculee Conception School
Ignace Public School
Ignace Secondary School

Keewatin schools

Keewatin Public School
St. Louis School

Kenora schools

Mine Centre school

Mine Centre Public School

Nestor Falls school

Nestor Falls School

Pickle Lake school

Crolancia School

Rainy River schools

Rainy River High School
Riverview School

Red Lake schools

Ecole catholique Des Etoiles-du-Nord
Red Lake District High School
Red Lake Madsen Public School
St. John School

Savant Lake school

Savant Lake Public School

Sioux Lookout schools

Sacred Heart School
Sioux Mountain Public School
Sioux North High School

Sioux Narrows school

Sioux Narrows Public School

Stratton school

Our Lady of the Way School

Vermilion Bay school

Lillian Berg School

Student's name *

First

Last

Student's preferred name

Student's date of birth *

Student's gender *

Student health history questions

Please list any allergies your student has. *

Please explain any reaction to a vaccine you student has had. *

Does your student have a history of fainting? *

Please list any serious medical condition your student has. *

If your student has a weak immune system or is taking a medication that increases the risk of infection (e.g., corticosteroids), please list. *

Consent information

Consenting adult’s name *

Relationship to student *

Home phone *

Work or mobile phone

Grade seven student?

Hepatitis B
Human Papilloma Virus
Meningococcal (Men CAYW)

I have read the fact sheets above for the vaccines listed on the Immunization Letter sent home. I understand the expected benefits and possible risks of the vaccines. I understand the possible risks to my student if not vaccinated. I am aware that I can contact Northwestern Health Unit with questions/ have had the opportunity to have my questions answered by Northwestern Health Unit. I understand that I can withdraw my consent at any time. I understand that my student may receive multiple needles in one day. This consent will be valid until series completion or up to two years.

I authorize Northwestern Health Unit to administer the vaccine(s) that include protection against the diseases listed on the Immunization Letter I received with the following number.

Immunization Consent Form number *

Personal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact the health unit at 800-830-5978 or see the privacy statement on our website at www.nwhu.on.ca.

By completing this consent form, I confirm that I am the legal guardian and have the authority to consent to this vaccine on behalf of this individual.