COVID-19 Vaccination Parental Consent Form

Name of parent / guardian (first name and surname)*:

Child’s Full name (first name and surname)*:

NHS number (if known):

Home address & Postcode*:

GP name and address:

Daytime telephone number of parent / guardian*:

Date of birth of Child (dd/mm/yyyy)*:

Ethnicity:

Gender*:
MaleFemalePrefer not to say

I am the parent / guardian of the above-named child
YesNo

I want my child to receive the full course of COVID-19 vaccinationI do not want my child to receive the full course of COVID-19 vaccination

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The COVID-19 vaccination will reduce the chance of you suffering from COVID-19 disease. Like all medicines, no vaccine is completely effective, and it takes a few weeks for your body to build up protection from the vaccine. Some people may still get COVID-19 despite having a vaccination, but this should lessen the severity of any infection.

The vaccine cannot give you COVID-19 infection, and two doses will reduce your chance of becoming seriously ill. Please inform the person giving the vaccination, if your child:

has had a severe reaction to any medicines, including vaccines,
is allergic to anything, or
has a condition for which he or she has, or is receiving medical treatment

Follow the guidance in your workplace, including wearing the correct personal protection equipment and taking part in any screening programmes. Like all medicines, vaccines can cause side effects. Most of these are mild and short-term, and not everyone gets them.

Please read the product information for more details on the vaccine and possible side effects by searching Coronavirus Yellow Card. You can also report suspected side effects on the same website or by downloading the Yellow Card app. Visit coronavirus-yellowcard.mhra.gov.uk