Please complete this form to authorize the Alliance to administer the influenza vaccine to your child. Prior to signing this form, you will need to read the Vaccine Information Statement from the Centers for Disease Control and Prevention.
If your child is age 2 years or older, he or she may be eligible to receive the intranasal flu vaccine, FluMist. If you would like your child to receive this type of flu vaccine, please complete this form for review with your pediatrician.
If your child is scheduled for a vaccine-only visit for any immunization, please bring this completed form to the visit.