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Get TX HISD No-Cost Flu Shot (IIV) Vaccine Consent Form 2018-2024

PEN. EVERY SECTION OF THIS FORM IS REQUIRED. Student Information Last Name First Name, Middle Initial Suffix Address Birth Date (month/date/year) Age Sex Name of School Grade Homeroom City State Zip Code Demographic Information (Circle one): White American Indian/Native Alaskan Black Asian Hispanic Other Parent/Guardian Information Last Name First Name, Middle Initial Suffix Email Address Home Phone Number Relationship to Student Cell Phone Number Required Health Ins.

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