For your convenience, school required immunizations for students ages 11+ will be offered at the Brookside Campus during the Back to School Resource Fair on Saturday, July 27 .

Students must be in compliance with the required immunizations. Students who fall out of compliance will not be able to return to school until the school nurse has verified the immunization requirements have been met. Students will not be allowed to begin or resume classes until the school nurse has verified the immunization requirements have been met.

Immunization Services
   TDaP immunization (ages 11+)
   Meningitis immunization (ages 11+)

Who is eligible and what payment methods are accepted?
Students, of qualifying age, attending Waukegan Public High School District 60 who meet the following requirements are eligible to receive the offered services:
   ★ Medicaid-insured students - Immunizations will be administered to those who provide proof of coverage during registration and onsite. Copies of insurance cards will be scanned on the day of the clinic.

   ★ Non-insured students - Immunizations provided to those without evidence of coverage shall pay $15.00 per vaccine.

   ★ Privately insured students of specific plans - Insurance claims for immunizations will be submitted for those who provide proof during registration and onsite. Copies of insurance cards will be scanned on the day of the clinic. The following plans are accepted:
      ☆ Aetna PPO
      ☆ BlueCross BlueShield Illinois PPO
      ☆ Cigna PPO
      ☆ Humana PPO
      ☆ United Healthcare PPO

Do I need to register ahead of time?
Yes, please provide the necessary demographic and medical information below. Each student needs their own appointment/registration. If you do not have insurance, you must select Not Insured (Electronically Pay $15.00).

Do I need to bring anything to my appointment?
   1. Insurance card (REQUIRED)
   2. Driver's License or Form of Identification of the insured parent (REQUIRED)
   3. Dress appropriately to receive an injection in the upper arm.

You are able to cancel your appointment through your confirmation email. If you have not received a confirmation email, please check your email's spam folder before you contact your school's coordinator.
Clinic Location
First Name
Last Name
Date of Birth
 
 
Parental/Guardian Consent
Please type your full name to electronically affirm consent as registrants parent/legal guardian. Signature
Email
Confirm Email
Mobile Phone Number
Gender
Emergency Contact Information
Name
Relationship
Phone
Insurance Billing Information
Insurance Provider
 
Services I'd like to receive
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.
Medical History Questions
Have you ever had an anaphylactic or severe allergy reaction to any of the vaccines or any component of a vaccine that you are choosing to receive today? Yes No
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to latex, chicken eggs, egg products, gelatin, neomycin, yeast, or thimerosal, which is found as a preservative in contact lens solution and some vaccines? Yes No
Do you have any history of Guillain-Barre Syndrome? Yes No
Have you ever been dizzy or faint when getting a vaccine or having your blood drawn? Yes No
Are you immunocompromised or taking medications that may cause you to have a decreased immune response to the vaccine? Yes No
Are you pregnant, trying to get pregnant, or breastfeeding? As some of these vaccines have not been tested in pregnancy or while breastfeeding, they should only be administered if the benefits outweigh the risks. It is recommended to wait at least 30 days after vaccination to try and get pregnant. Yes No
Have you had other live vaccines (MMR, Yellow Fever, Varicella) or a TB test in the past 4 weeks? Yes No
Have you received passive antibody therapy as treatment for COVID-19 in the past 90 days? Yes No
Do you have a bleeding disorder or are you taking a blood thinner? Yes No
Do you have a progressive neurological disorder, uncontrolled epilepsy or progressive encephalopathy? Yes No
Did you ever develop encephalopathy (brain disorder) without an identifiable cause within 7 days of administration of prior DTP, DTaP or Tdap? Yes No
Do you have polycythemia vera (rare blood disorder) or Leber’s disease (rare eye disorder) or ever had an allergic reaction to hydroxocobalamin or cyanocobalamin? Yes No
Have you received any previous pneumonia vaccinations? Yes No
Have you had a serious reaction to a previous dose of PPV (Pneumococcal Polysaccharide Vaccine) or any component of the vaccine, including a vaccine containing diphtheria toxoid? Yes No
Terms & Conditions
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the patient is at least 10 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Passport Health or Preventive Health Partners or the Illinois Departments of Public Health or their agents to administer vaccines to the patient named above. Additionally, in the event a school or sports physical is needed, I authorize consent for the patient named above. I understand that this document provides consent for receipt of the complete vaccine series, should a vaccine require more than one shot to complete the series. I have read or had explained to me information provided about the vaccine that I, or my child (if applicable), is going to receive. I have had the chance to ask questions that were answered to my satisfaction and I understand the risks and benefits of vaccination and I voluntarily assume full responsibility for any reactions that may result. I have been provided with access to the Vaccine Information Sheet (VIS) on the vaccines I, or my child (if applicable) have elected to receive. If I, or my child (if applicable) experience a severe reaction, I further consent to any emergency treatment or emergency hospital transportation required to care for any vaccine reaction that may occur at the vaccination location for myself or my child (if applicable) including administration of the medication Epinephrine which is used for severe allergic reactions. On behalf of myself, my child (if applicable), my heirs and personal representatives, I hereby release and hold harmless Passport Health, Preventive Health Partners, the State of Illinois, the Illinois Department of Public Health, the School District I, or my child (if applicable), attends and its Board of Education and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above on the patient listed above.




Need help? Contact us at adobbs@wps60.org


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