School Compliance Consent Routine Immunizations In-School Event:Please complete each section and submit the form.Select School Event or System(Required)Please Select School SystemFort Wayne Community SchoolsNorth Miami Community Schools 3/12/2025East Allen County SchoolsWarsaw Community Schools 5/2/2025Holy Cross Health Fair 5/20 & 5/21Select Fort Wayne School(Required)Select SchoolNorth Side 4/24/20255/1/25 Health Fair at NorthropWayne 5/13/2025This field is hidden when viewing the formSelect East Allen School(Required)Please Select EACS SchoolPrince Chapman Academy 3/26/2025New Haven Intermediate 3/27/2025Heritage K-12 4/11/2025Select Warsaw Community School(Required)Warsaw Community High SchoolEdgewood Middle SchoolLakeview Middle SchoolGateway Education CenterClaypool ElementaryEisenhower ElementaryHarrison ElementaryJefferson ElementaryLeesburg ElementaryLincoln ElementaryMadison ElementaryWashington Elementary SchoolGrade Level for 2025-2026 School Year(Required)Select Grade Level for Next School YearKindergarten Compliance Vaccine Clinic6th Grade Compliance Vaccine Clinic11th/12th Grade Compliance Vaccine ClinicOther Student’s Information:Student Name(Required) First Middle Inital Last Child's Date of birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required)Select OneMaleFemaleHome Address(Required)City(Required)State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip(Required)Race(Required)PLease Select OneWhiteAfrican AmericanAsianAmerican IndianNatl. Hawaiian, Pac IslAlaskan NativeOtherEthnicity(Required)Please Select OneHispanic/LatinoNot Hispanic/LatinoDeclined to answerLanguage(Required)Please Select OneEnglishSpanishBurmeseOtherChild's Primary Care Provider(Required)Is the Student Disabled?(Required) Yes No Prefer not to say Does the student have any of the following:(Required) ADHD Autism or ASD Anxiety or Depression ODD Hearing loss/Deafness Vision loss Physical impairment in one or more limb Learning or intellectual impairment Neurological disorder (Epilepsy, MS, Muscular Dystrophy) Speech or language difficulties None of these apply Super Shot understands that some students may need extra accommodations to make sure that the vaccination process goes as smoothly as possible. If extra accommodations are needed, call (260) 424-7468 to make an appointment at our office located at 1515 Hobson Rd, Fort Wayne, IN 46805. Our Sensory room is available during clinic hours for patients of any age. Contact Information:Parents/Guardian Name(Required)First NameMiddle InitialLast Name Add RemoveMobile Phone Number(Required)Email Address(Required) Number of People in HouseholdPlease Select One12345678910+Choose not to answerCurrent Household Income(Required)Please Select OneBelow $11,800$11,881-$24,300$24,301-$36,450$36,451-$48,600$48,601-$60,750$60,751-$72,900Over $72,901Decline to Answer 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. Medicaid Insurance Provider(Required)Select Medicaid InsuranceAnthem BCBSCareSource-INManaged Health Services-MHSMDWiseOtherPrivate Insurance Company(Required)Private Insurance CompanyAetnaAnthem BCBSCareSourceManaged Health Services-MHS AmbetterCignaMDWiseParkview Signature Care - Signature CarePHP of Northern IndianaUnited HealthcareThree Rivers PreferredLutheran PreferredOther (Enter Below)Other Insurance Company(Required)Member ID(Required)Group #(Required)Policy HolderName(Required) First Middle Initial Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer(Required)Relationship to Student(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. Medical Information:Please select Yes or No for all questions. Answers are for the person getting the vaccine.Is the student allergic to a vaccine component or latex (ex. gentamicin, alginine, gelatin, or MSG)? (if yes, please note)(Required) Yes No List vaccine component allergies(Required) Add RemoveHas the student had a serious reaction to a vaccine in the past?(Required) Yes No Describe the serious reaction:(Required)Is the student pregnant or is there a chance they could become pregnant within a month of being vaccinated?(Required) Yes No Not Applicable Is someone in the child's home immunocompromised or requires a protective environment?(Required) Yes No Does the student have any of the following: (mark all that apply)(Required) Chronic Heart Disease Diagnosed with Myocarditis or MIS-C Kidney Disease Liver Disease Crohn's Disease Psoriasis Complement Component Deficiency Asplenia Takes a medication that lowers resistance to infection Takes aspirin or Blood thinners History of Chickenpox History of Gillian-Barre syndrome Diabetes/Metabolic Disorder History or family history of Nervous System Disorder Asthma/RAD Received blood products or immune gamma globulin in the last year CSF Leak Cochlear Implant Weakened Immune System, Cancer, Lupus, HIV/AIDS None of the above The following vaccines are required by the state of Indiana. A recommended vaccine may also be suggested by age group to prevent illness and/or cancer, but is not required. Your school nurse or a Super Shot representative will review your student's shot record to review which vaccines are needed. Your student will not receive any vaccines that are not indicated as due. Please select which vaccines you wish for your student to receiveI consent for my student to receive the following required Kindergarten vaccines(Required) Combination vaccine-MMR(Measles, Mumps, Rubella) & Varicella(Chicken Pox), Combination Vaccine- DTaP(Diphtheria, Tetanus, Pertussis) & IPV(Inactivated Polio) Select AllI understand that MMR and Varicella are live vaccines and that my child will not receive other live vaccines within 28 days of receiving this vaccine.(Required) Yes No I consent for my student to receive the following required 6th Grade vaccines:(Required) Tdap (Diphtheria, Tetanus, Pertussis) MCV4 (Meningococcal serogroups A, C, W, & Y) I consent for my student to receive the following recommended vaccine for cancer prevention:(Required) HPV-Prevents 9 strains of Human Papilloma Viruses that can cause head, neck, cervical, vaginal, vulvar, penile, and anal cancers. I do not want my student to receive the HPV cancer preventing vaccine. I consent for my student to receive the following required 12th Grade vaccines:(Required) MCV4-Second Dose-(Meningococcal serogroups A, C, W, & Y) I consent for my student to receive the following recommended 12th Grade vaccines:(Required) MenB-Prevents B strain of Meningitis. This strain accounts for 9 out of 10 cases of Meningitis for young people. Some colleges and the military require this vaccine. HPV-Prevents 9 strains of Human Papilloma Viruses that can cause head, neck, cervical, vaginal, vulvar, penile, and anal cancers. I don't want my student to receive either of these. I consent to Super Shot providing catch-up doses, if needed, of any state required vaccines for my student:(Required) Yes, catch my student up if needed. No, do not catch my student up. Super Shot checks each student's vaccination record individually. If additional vaccines are indicated, we will reach out to let you know what is needed to remain in compliance with Indiana required immunizations. With your consent, we can provide the vaccines indicated to catch your student up at the time of service in your school. Please call (260)424-7468 if you have any questions. I consent for my student to participate in the In-School Flu Clinic for the fall of 2025.(Required) Yes No Starting mid-September, Super Shot is providing a Flu Clinic in most area schools. Skip paying a co-pay at your PCP this year or visiting a crowded pharmacy. Super Shot will bring the immunity to you! Communication It's ok to call me It's ok to TXT me The HIPAA Notice of Privacy Policy available at https://supershot.org/privacy-policy/ CDC Vaccine Information Statements for all vaccines the child named above will receive are available at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html I have read and understand all information provided at the links above and understand the benefits of vaccines, as well as the risks which includes the contraindications, precautions, and possible side effects of each vaccine administered. I give permission to Super Shot to give the child named above the vaccines selected in my absence, to communicate information provided with other healthcare providers as needed, for EMR data entry, insurance billing for services provided, and storage according to Indiana Department of Health policies. I relieve Super Shot, Inc and all personnel of any liability for any reactions that may occur. I have the legal authority, based on my relationship to the child named above, to consent to this vaccine administration.Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY Parent/Guardian Name(Required)NameThis field is for validation purposes and should be left unchanged. Routine Immunizations In-School Event:Please complete each section and submit the form.Select School Event or System(Required)Please Select School SystemFort Wayne Community SchoolsNorth Miami Community Schools 3/12/2025East Allen County SchoolsWarsaw Community Schools 5/2/2025Holy Cross Health Fair 5/20 & 5/21Select Fort Wayne School(Required)Select SchoolNorth Side 4/24/20255/1/25 Health Fair at NorthropWayne 5/13/2025This field is hidden when viewing the formSelect East Allen School(Required)Please Select EACS SchoolPrince Chapman Academy 3/26/2025New Haven Intermediate 3/27/2025Heritage K-12 4/11/2025Select Warsaw Community School(Required)Warsaw Community High SchoolEdgewood Middle SchoolLakeview Middle SchoolGateway Education CenterClaypool ElementaryEisenhower ElementaryHarrison ElementaryJefferson ElementaryLeesburg ElementaryLincoln ElementaryMadison ElementaryWashington Elementary SchoolGrade Level for 2025-2026 School Year(Required)Select Grade Level for Next School YearKindergarten Compliance Vaccine Clinic6th Grade Compliance Vaccine Clinic11th/12th Grade Compliance Vaccine ClinicOther Student’s Information:Student Name(Required) First Middle Inital Last Child's Date of birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required)Select OneMaleFemaleHome Address(Required)City(Required)State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip(Required)Race(Required)PLease Select OneWhiteAfrican AmericanAsianAmerican IndianNatl. Hawaiian, Pac IslAlaskan NativeOtherEthnicity(Required)Please Select OneHispanic/LatinoNot Hispanic/LatinoDeclined to answerLanguage(Required)Please Select OneEnglishSpanishBurmeseOtherChild's Primary Care Provider(Required)Is the Student Disabled?(Required) Yes No Prefer not to say Does the student have any of the following:(Required) ADHD Autism or ASD Anxiety or Depression ODD Hearing loss/Deafness Vision loss Physical impairment in one or more limb Learning or intellectual impairment Neurological disorder (Epilepsy, MS, Muscular Dystrophy) Speech or language difficulties None of these apply Super Shot understands that some students may need extra accommodations to make sure that the vaccination process goes as smoothly as possible. If extra accommodations are needed, call (260) 424-7468 to make an appointment at our office located at 1515 Hobson Rd, Fort Wayne, IN 46805. Our Sensory room is available during clinic hours for patients of any age. Contact Information:Parents/Guardian Name(Required)First NameMiddle InitialLast Name Add RemoveMobile Phone Number(Required)Email Address(Required) Number of People in HouseholdPlease Select One12345678910+Choose not to answerCurrent Household Income(Required)Please Select OneBelow $11,800$11,881-$24,300$24,301-$36,450$36,451-$48,600$48,601-$60,750$60,751-$72,900Over $72,901Decline to Answer 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. Medicaid Insurance Provider(Required)Select Medicaid InsuranceAnthem BCBSCareSource-INManaged Health Services-MHSMDWiseOtherPrivate Insurance Company(Required)Private Insurance CompanyAetnaAnthem BCBSCareSourceManaged Health Services-MHS AmbetterCignaMDWiseParkview Signature Care – Signature CarePHP of Northern IndianaUnited HealthcareThree Rivers PreferredLutheran PreferredOther (Enter Below)Other Insurance Company(Required)Member ID(Required)Group #(Required)Policy HolderName(Required) First Middle Initial Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer(Required)Relationship to Student(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. Medical Information:Please select Yes or No for all questions. Answers are for the person getting the vaccine.Is the student allergic to a vaccine component or latex (ex. gentamicin, alginine, gelatin, or MSG)? (if yes, please note)(Required) Yes No List vaccine component allergies(Required) Add RemoveHas the student had a serious reaction to a vaccine in the past?(Required) Yes No Describe the serious reaction:(Required)Is the student pregnant or is there a chance they could become pregnant within a month of being vaccinated?(Required) Yes No Not Applicable Is someone in the child's home immunocompromised or requires a protective environment?(Required) Yes No Does the student have any of the following: (mark all that apply)(Required) Chronic Heart Disease Diagnosed with Myocarditis or MIS-C Kidney Disease Liver Disease Crohn’s Disease Psoriasis Complement Component Deficiency Asplenia Takes a medication that lowers resistance to infection Takes aspirin or Blood thinners History of Chickenpox History of Gillian-Barre syndrome Diabetes/Metabolic Disorder History or family history of Nervous System Disorder Asthma/RAD Received blood products or immune gamma globulin in the last year CSF Leak Cochlear Implant Weakened Immune System, Cancer, Lupus, HIV/AIDS None of the above The following vaccines are required by the state of Indiana. A recommended vaccine may also be suggested by age group to prevent illness and/or cancer, but is not required. Your school nurse or a Super Shot representative will review your student’s shot record to review which vaccines are needed. Your student will not receive any vaccines that are not indicated as due. Please select which vaccines you wish for your student to receiveI consent for my student to receive the following required Kindergarten vaccines(Required) Combination vaccine-MMR(Measles, Mumps, Rubella) & Varicella(Chicken Pox), Combination Vaccine- DTaP(Diphtheria, Tetanus, Pertussis) & IPV(Inactivated Polio) Select AllI understand that MMR and Varicella are live vaccines and that my child will not receive other live vaccines within 28 days of receiving this vaccine.(Required) Yes No I consent for my student to receive the following required 6th Grade vaccines:(Required) Tdap (Diphtheria, Tetanus, Pertussis) MCV4 (Meningococcal serogroups A, C, W, & Y) I consent for my student to receive the following recommended vaccine for cancer prevention:(Required) HPV-Prevents 9 strains of Human Papilloma Viruses that can cause head, neck, cervical, vaginal, vulvar, penile, and anal cancers. I do not want my student to receive the HPV cancer preventing vaccine. I consent for my student to receive the following required 12th Grade vaccines:(Required) MCV4-Second Dose-(Meningococcal serogroups A, C, W, & Y) I consent for my student to receive the following recommended 12th Grade vaccines:(Required) MenB-Prevents B strain of Meningitis. This strain accounts for 9 out of 10 cases of Meningitis for young people. Some colleges and the military require this vaccine. HPV-Prevents 9 strains of Human Papilloma Viruses that can cause head, neck, cervical, vaginal, vulvar, penile, and anal cancers. I don’t want my student to receive either of these. I consent to Super Shot providing catch-up doses, if needed, of any state required vaccines for my student:(Required) Yes, catch my student up if needed. No, do not catch my student up. Super Shot checks each student’s vaccination record individually. If additional vaccines are indicated, we will reach out to let you know what is needed to remain in compliance with Indiana required immunizations. With your consent, we can provide the vaccines indicated to catch your student up at the time of service in your school. Please call (260)424-7468 if you have any questions. I consent for my student to participate in the In-School Flu Clinic for the fall of 2025.(Required) Yes No Starting mid-September, Super Shot is providing a Flu Clinic in most area schools. Skip paying a co-pay at your PCP this year or visiting a crowded pharmacy. Super Shot will bring the immunity to you! Communication It’s ok to call me It’s ok to TXT me The HIPAA Notice of Privacy Policy available at https://supershot.org/privacy-policy/ CDC Vaccine Information Statements for all vaccines the child named above will receive are available at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html I have read and understand all information provided at the links above and understand the benefits of vaccines, as well as the risks which includes the contraindications, precautions, and possible side effects of each vaccine administered. I give permission to Super Shot to give the child named above the vaccines selected in my absence, to communicate information provided with other healthcare providers as needed, for EMR data entry, insurance billing for services provided, and storage according to Indiana Department of Health policies. I relieve Super Shot, Inc and all personnel of any liability for any reactions that may occur. I have the legal authority, based on my relationship to the child named above, to consent to this vaccine administration.Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY Parent/Guardian Name(Required)PhoneThis field is for validation purposes and should be left unchanged.
