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SHAWNEE COUNTY HEALTH DEPARTMENT - School Vaccine Clinic Registration

Please complete at least 2 business days before coming to the Shawnee County Health Department (SCHD) School Vaccine Clinic.

This form is intended for use by individuals coming to a SCHD School Vaccine Clinic. If you have any questions, please call 785-251-5700.

By completing this now, you will save time completing paperwork at the clinic. If you close your browser window before completing, you will need to start at the beginning.

Remember to bring your photo ID and insurance card with you when you come.

For a copy of the Shawnee County Health Department's Notice of Privacy Practices - click here for English or click here for Spanish

1. School Information: *This question is required.

School District

School Name

2. Client's Full Name:

First Name *This question is required.

Middle Initial

Last Name *This question is required.

3. Client's Preferred Name:

4. Client's Date of Birth: (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Client's Gender: *This question is required.

6. Client's Race (select all that apply): *This question is required.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Choose not to disclose
Other Please enter an 'other' value for this selection.

7. Client's Ethnicity: *This question is required.

Please enter an 'other' value for this selection.

Client's Origin:

Please enter an 'other' value for this selection.

8. Client's Preferred Language:

9. Client's Address: *This question is required.

Street

City

State

Zip This question requires a valid number format.

10. Client's Phone Number (no dashes) This question requires a valid number format.

11. Type of Medical Insurance: *This question is required.

Client's Medical Insurance Information:

Insurance Provider *This question is required.

Cardholder Name *This question is required.

Cardholder's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Relationship to Cardholder: *This question is required.

Identification Number *This question is required.

Group Number

12. Is the client a minor?