In-School Participation Submission Form In-School Health Screener & Insurance Step 1 of 4 - Event 25% Vaccination Event:School System(Required)Select Super Shot EventCanterbury SchoolsSACSEACSTimothy L. Johnson AcademyConcordia High SchoolGarrett-Keyser Butler Schools 9/20Warsaw Community SchoolsDekalb Central SchoolsBishop LuersMLK Montessori SchoolThis field is hidden when viewing the formFWCS School(Required)AbbettAdamsArlingtonBlackhawkBloomingdaleBrentwoodBuncheCroningerFairfieldForest ParkFranke ParkGlenwood ParkHaleyHarrisHarrison HillHollandIndian VillageIrwinJeffersonKekiongaLakesideLaneLincolnLindleyMaplewoodMemorial ParkMiamiNew Tech AcademyNorth SideNorthcrestNorthropNorthwoodPortagePriceScottShambaughShawneeSniderSouth SideSouth WayneSt JoeStudyTowles IntermediateVirtual AcademyWashingtonWashington CenterWayneWaynedaleWeisser ParkWhitney YoungWhich FWCS school does your student attend?EACS SchoolCedarville ElementaryEast Allen UniversityEast Allen Alternative SchoolEast Allen Career CenterHeritage ElementaryHeritage Jr/Sr High SchoolLeo ElementaryLeo Jr/Sr High SchoolNew Haven Intermediate SchoolNew Haven Junior High SchoolNew Haven Primary SchoolPaul Harding Jr High SchoolPrince Chapman AcademySouthwick Elementary SchoolWoodlan ElementaryWoodlan Jr/Sr High SchoolWhich EACS school does your student attend?SACS SchoolAboite ElementaryCovington ElementaryDeer Ridge ElementaryLafayette Meadows ElementaryWhispering Meadows ElementarySummit MiddleWoodside MiddleHomestead High SchoolWhich SACS school does your student attend?Warsaw Community SchoolsWarsaw Community High SchoolEdgewood Middle SchoolLakeview Middle SchoolGateway Education CenterClaypool ElementaryEisenhower ElementaryHarrison ElementaryJefferson ElementaryLeesburg ElementaryLincoln ElementaryMadison ElementaryWashington Elementary SchoolDeKalb Central SchoolWaterloo Elementary 10/28 2:30p-4pJames R. Watson Elementary 10/28 2:30p-4pDeKalb Middle School 10/29 3:30p-5pPlease complete each section and hit 'Next'Child's Name(Required) First Middle Initial Last Child's Date of birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Required Health Insurance Information:Select One(Required) Private Insurance Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise) No Insurance: I certify that the patient is not covered by any health insurance. Insurance Company(Required)Member ID(Required)Group #(Required)Policy HolderName First Middle Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Patient(Required)Select OneSelfSpouseChildOtherGrandparentGrandchildNephew or NieceFoster ChildWardStepson or StepdaughterEmployeeHandicapped DependentSponsored DependentDependent of a Minor DependentSignificant OtherMotherFatherEmancipated MinorLife PartnerUpload Insurance Card Image (Front)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.Upload Insurance Card Image (Back)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB. Health Screener Questions:Please select Yes or No for all questions. Answers are for the person getting the vaccine.Is your child allergic to any vaccine Component such as gentamicin, arginine, gelatin, or MSG? (if yes, please note)(Required) Yes No List applicable allergies(Required) Add RemoveHas your child had a serious reaction to a vaccine in the past (ex: fainting)? If yes, please note(Required) Yes No If yes, please list the reaction type here:(Required)Is your child pregnant or could they become pregnant within a month of being vaccinated?(Required) Yes No Not Applicable Is your child on aspirin therapy or blood thinners?(Required) Yes No Will your child be on antivirals within 3 weeks of vaccination?(Required) Yes No Does your child live or have close contact with someone who is severely immunocompromised or requires a protective environment?(Required) Yes No Does the patient have any of the following: (mark all that apply)(Required) Asthma/RAD Weakened Immune System, Cancer, Lupus, HIV/AIDS Diabetes/Metabolic Disorder Nervous System Issues Kidney Disorders Blood Disorders History of Chickenpox History of Gillian-Barre syndrome Family History of Seizures Cochlear Implant Currently on long-term aspirin therapy, Tamiflu, Relenza, or amatadine/rimantadine None of the above ConsentCommunication It's ok to call me It's ok to TXT me All information I have provided on the consent for vaccination is true and correct. I have legal authority to consent for all vaccination services rendered. I consent to my child, named above, to receive in-school Influenza clinic services from Super Shot. I am aware of the HIPAA Notice of Privacy Policy available at supershot.org. I am aware and understand the CDC Vaccine Information Statements for the vaccines the patient will receive today available at https://www.cdc.gov/vaccines/hcp/vis/index.html I give permission to Super Shot to give the patient vaccines indicated in my absence and use all information provided to communicate with other healthcare providers or other entities as needed, for data entry, billing, and storage according to Indiana Department of Health policies. By signing below I agree to the payment option indicated for services performed. I understand that a claim will be filed to my insurance company for vaccination services rendered. Signature(Required)Date MM slash DD slash YYYY Parent/Guardian Name(Required)PhoneThis field is for validation purposes and should be left unchanged.
