Minor Vaccination Authorization

Authorization to Administer COVID-19 Vaccine in Absences of Parent/Legal Guardian

I,(Parent/Legal Guardian Name):

Relationship to Child:

Herby Authorize:

To Bring my Child:

To the J&K Healthy Choice and its affiliates, vaccine appointment and authorize J&K Healthy Choice to administer the COVID-19 vaccine to my child in my absence

I GIVE CONSENT for the child named at the top of this form to get vaccinated with the COVID-19 Vaccine and reviewed and agree to the information

Name of the Parent or Legal Guardian

First Name:*

Last Name:*

Phone Number:

Address:

Child’s Date of Birth:

Age:

For 12- through 15-years-olds who will not be accompanied by their parent or legal guardian only

Name of responsible adult who I authorize to accompany the child:

I am an emancipated or self-sufficient minor or married or previously married:

If you check this box, you may be asked to attest to this at your vaccine appointment

Minor Vaccination Authorization

Authorization to Administer COVID-19 Vaccine in Absences of Parent/Legal Guardian

Name of the Parent or Legal Guardian

Minority-Owned Business

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