Health Compliance FL SHOTS Parental Consent Form for Dual Enrollment

If your child was vaccinated in the State of Florida, Health Compliance may be able to locate their records and facilitate the registration process. By completing this form you as parent/legal guardian are allowing Health Compliance to run their information through the FL SHOTS state immunization database. If HC is able to locate your immunization information, this may facilitate your registration process.

IMPORTANT NOTE: If your child was not vaccinated in the state of Florida, please visit https://go.fiu.edu/immunizationform to access the Immunization Documentation form. The form MUST be completed by your health care provider and submitted to the Health Compliance office at immune@fiu.edu.

Student Name: Student Name: First Last
FIU Panther ID:
Student Date of Birth: Student Date of Birth: / MM / DD YYYY
Student School Email:
Parent/Legal Guardian Name: Parent/Legal Guardian Name: First Last
Parent/Legal Guardian Email:
Parent/Legal Guardian Phone: Parent/Legal Guardian Phone: - ### - ### ####
Home Address: Home Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please select term when you are entering FIU:

Please select term when you are entering FIU: Summer/Early Fall Fall Spring
Calendar Year of Starting Semester (ex. 2023):
Gender:

Gender: Male Female Other
PARENTAL/LEGAL GUARDIAN SIGNATURE INSTRUCTIONS:
Draw your signature into the box below. By signing this document, I am allowing Health Compliance to run my child's record through the FL SHOTS state immunization database. I understand this is a legal representation of my signature.

Draw or Type

By signing this document, I am allowing Health Compliance to run my child's record through the FL SHOTS state immunization database. I affirm I am the parent/legal guardian for the student on this form and understand this is a legal representation of my signature. Clear

Full Name

By signing this document, I am allowing Health Compliance to run my child's record through the FL SHOTS state immunization database. I affirm I am the parent/legal guardian for the student on this form and understand this is a legal representation of my signature.
Parent/Legal guardian Government Issued ID:
A Valid Government Issued Picture ID must be uploaded of the Parent/Legal guardian signing the consent form.

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