Consent Form For SBI

Republika ng Pilipinas
Region IV- A
DIVISION:
SCHOOL:
ADDRESS:
Dear Parent Guardian:
This school as a Public Elementary/Secondary School will provide School- Base Immunization (SBI) of Measles-Rubella
(MR) and Tetanus- Diphteria (TD) vaccines to Grade 1 and Grade 7 students in coordination with the Department of Health
(DOH) and the Local Government Unit (LGU).
This Notification is being issued to you as information of the activity that will be conducted for SY 2024- 2025. If you
have further questions, clarifications on this matter. Please get in touch with the Principal or School Head.
Thank you very much.
Name of School Teacher
ACKNOWLEDGEMENT AND CONSENT
I have read and understood the information regarding the intended immunization services to be given to my child.
Name of Child Date of Birth (mm/dd/yyyy)

Surname: First name: Middle name:
Contact information Age Sex

Contact Number: School:
PRE- VACCINATION CHECKLIST (FOR PARENT/GUARDIAN TO COMPLETE)

Your consent is required before your child can be immunized at school. Request clearance from your physician if any of the
following applies (kindly check (N) if any condition applies to your chikd)
My child had history of severe allergy to measles- containing or TD vaccines.

My child has severe illness
Primary Immune- defi

Suppressed immune response from medication
Leukemia
Lymphoma
Lymphoma
Other generalized malignancies
None, my child is relatively healthy.
CONSENT FOR IMMUNIZATION

(Please check in the box provided)
Yes, I will allow my child to be provided the immunization services as per DOH recommendations.
Grade 1 (MR-Td)
Grade 7 (MR-Td)
No, I will not allow my child to receive the immunization service because
I understand that by opting out of the required immunization, my child may be at a higher risk of contracting vaccine
preventable diseases. By signing this waiver, I acknowledge that I have read and understood the information provided
above. I voluntarily choose to exempt my child from the required school immunization.
Name and Signature of Parent/ Guardian

Republika ng Pilipinas
Region IV- A
DIVISION:
SCHOOL:
ADDRESS:
Dear Parent Guardian:
This school as a Public Elementary/Secondary School will provide School- Base Immunization (SBI) of
Human Papillomavirus (HPV) for Grade 4 Female students in coordination with the Department of Health (DOH) and the Local
Government Unit (LGU).
This Notification is being issued to you as information of the activity that will be conducted for SY 2024- 2025. If you
have further questions, clarifications on this matter. Please get in touch with the Principal or School Head.
Thank you very much.
Name of School Teacher
ACKNOWLEDGEMENT AND CONSENT
I have read and understood the information regarding the intended immunization services to be given to my child.
Name of Child Date of Birth (mm/dd/yyyy)

Surname: First name: Middle name:
Contact information Age Sex

Contact Number: School:
PRE- VACCINATION CHECKLIST (FOR PARENT/GUARDIAN TO COMPLETE)

Your consent is required before your child can be immunized at school. Request clearance from your physician if any of the
following applies (kindly check (N) if any condition applies to your child)
My child had history of severe allergy to measles- containing or TD vaccines.

My child has severe illness
Primary Immune- defi

Suppressed immune response from medication
Leukemia
Lymphoma
Lymphoma
Other generalized malignancies
None, my child is relatively healthy.
CONSENT FOR IMMUNIZATION

(Please check in the box provided)
Yes, I will allow my child to be provided the immunization services as per DOH recommendations.
Grade 1 (MR-Td)
Grade 7 (MR-Td)
Grade 4 Female only (HPV)
No, I will not allow my child to receive the immunization service because
I understand that by opting out of the required immunization, my child may be at a higher risk of contracting vaccine
preventable diseases. By signing this waiver, I acknowledge that I have read and understood the information provided
above. I voluntarily choose to exempt my child from the required school immunization.
Name and Signature of Parent/ Guardian

Consent Form For SBI

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Republika ng Pilipinas

Dear Parent Guardian:

Thank you very much.

Name of School Teacher

ACKNOWLEDGEMENT AND CONSENT

Name of Child Date of Birth (mm/dd/yyyy)

Contact information Age Sex

PRE- VACCINATION CHECKLIST (FOR PARENT/GUARDIAN TO COMPLETE)

My child had history of severe allergy to measles- containing or TD vaccines.

Primary Immune- defi

CONSENT FOR IMMUNIZATION

Name and Signature of Parent/ Guardian

Dear Parent Guardian:

Thank you very much.

Name of School Teacher

ACKNOWLEDGEMENT AND CONSENT

Name of Child Date of Birth (mm/dd/yyyy)

Contact information Age Sex

PRE- VACCINATION CHECKLIST (FOR PARENT/GUARDIAN TO COMPLETE)

My child had history of severe allergy to measles- containing or TD vaccines.

Primary Immune- defi

CONSENT FOR IMMUNIZATION

Name and Signature of Parent/ Guardian

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