COVID-19 Vaccination Consent Form CLICK HERE FOR COVID-19 VACCINE INGREDIENTS Personal Details Note: Questions marked by * are mandatory *This is a mandatory field. Young Person's First Name: *This is a mandatory field. Young Person's Surname: *This is a mandatory field. Date of Birth: *This is a mandatory field. Age: Please Select An Option 12131415 *This is a mandatory field. Flat number or House Name/Number: *This is a mandatory field. Street Name: *This is a mandatory field. City: County: *This is a mandatory field. Postcode: *This is a mandatory field. Gender: Please Select An Option Male (cis or trans)Female (cis or trans)Non-BinaryRather Not Say *This is a mandatory field. Ethnicity: Please Select An Option White BritishWhite IrishWhite OtherBlack CaribbeanBlack AfricanBlack OtherIndianPakistaniBangladeshiAsian OtherWhite & Black CaribbeanWhite & Black AfricanWhite & AsianMixed OtherChineseAny Other *This is a mandatory field. Contact number for parent/legal guardian: NHS Number (If Known): *This is a mandatory field. School: Please Select An Option Harris Academy South Norwood, Spurgeon RoadHarris Primary Academy Croydon Addington Valley AcademyAerodrome Primary AcademyAl-Khair Boys Secondary SchoolAl-Khair Girls' SchoolAl-Khair Preparatory SchoolAll Saints CofE Primary SchoolApplegarth AcademyArchbishop Tenison's CofE High SchoolArk Blake AcademyArk Oval Primary AcademyAtwood Primary AcademyBeaumont Primary SchoolBeckmead SchoolBensham Manor SchoolBeulah Infants' SchoolBeulah Junior SchoolBroadmead Primary SchoolCACFO UK Education CentreCambridge Tutors CollegeCastle Hill AcademyChestnut Park Primary SchoolChipstead Valley Primary SchoolChrist Church CofE Primary School - PurleyColoma Convent Girls' SchoolCoombe Wood SchoolCoulsdon CofE Primary SchoolCourtwood Primary SchoolCressey CollegeCroydon High SchoolCroydon Metropolitan CollegeCumnor House School - BoysCumnor House School - GirlsCypress Primary SchoolDavid Livingstone AcademyJohn WoodDownsview Primary and Nursery SchoolEcclesbourne Primary SchoolElmhurst SchoolElmwood Infant SchoolElmwood Junior SchoolFairchildes Primary SchoolForest AcademyForestdale Primary SchoolQuest Primary SchoolGonville AcademyGood Shepherd Catholic Primary and Nursery SchoolGreenvale Primary SchoolGresham Primary SchoolHarris Primary Academy CroydonHarris Academy PurleyHarris Academy South Norwood, CumberlowHarris Aspire AcademyHarris City Academy Crystal PalaceHarris Federation Post 16Harris Invictus Academy CroydonHarris Primary Academy BensonHarris Primary Academy Haling ParkHarris Primary Academy KenleyHarris Primary Academy Purley WayHarris Professional Skills Sixth FormHeathfield AcademyHeavers Farm Primary SchoolHillcrestHoward Primary SchoolKenley Primary SchoolKensington Avenue Primary SchoolKeston Primary SchoolKrishna Avanti Primary SchoolLaleham Lea SchoolMargaret Roper Catholic Primary SchoolMeridian High SchoolMonks Orchard Primary SchoolNew Valley Primary SchoolNorbury High School for GirlsNorbury Manor Primary SchoolOakwood SchoolOasis Academy ArenaOasis Academy ByronOasis Academy CoulsdonOasis Academy RyelandsOasis Academy Shirley ParkOld Palace of John Whitgift SchoolOneschool Global Uk Kenley and Carshalton CampusOrchard Park High - CroydonOrchard Way Primary SchoolPark Hill Infant SchoolPark Hill Junior SchoolPaxton Academy Sports And SciencePriory SchoolPurley Oaks Primary SchoolRed Gates SchoolReedham Park School LimitedRegina Coeli Catholic Primary SchoolRiddlesdown CollegiateRidgeway Primary SchoolRobert Fitzroy AcademyRockmount Primary SchoolRowdown Primary SchoolRoyal Russell SchoolRutherford SchoolSaffron Valley CollegiateSelsdon Primary and Nursery SchoolShirley High School Performing Arts CollegeSmitham Primary SchoolSouth Norwood PrimarySt Aidan's Catholic Primary SchoolSt Andrew's CofE SchoolSt Chad's Catholic Primary SchoolSt Cyprian's Greek Orthodox Primary AcademySt David's SchoolSt Giles SchoolSt James the Great RC Primary and Nursery SchoolSt John's CofE Primary SchoolSt Joseph's CollegeSt Joseph's RC Infant SchoolSt Joseph's RC Junior SchoolSt Mark's Church of England Primary AcademySt Mary's Catholic High SchoolSt Mary's Catholic Infant SchoolSt Nicholas SchoolSt Peter's Primary SchoolSt Thomas Becket Catholic Primary SchoolSt. Mary's Catholic Junior SchoollThe Archbishop Lanfranc AcademyThe BRIT SchoolThe Cedars SchoolThe Crescent Primary SchoolThe Hayes Primary SchoolThe Laurels SchoolThe Minster Junior SchoolThe Minster Nursery and Infant SchoolThe New SchoolThe Quest AcademyThe Write TimeThomas More Catholic SchoolTrinity SchoolTudor AcademyWest Thornton Primary SchoolWhitehorse Manor BrigstockWhitehorse Manor Infant SchoolWhitehorse Manor Junior SchoolWhitgift SchoolWinterbourne Boys' AcademyWinterbourne Junior Girls' SchoolWinterbourne Nursery and Infants' SchoolWoodcote High SchoolWoodcote Primary SchoolWoodside Primary School *This is a mandatory field. GP Surgery Name: *This is a mandatory field. What was the date of your child's first COVID-19 Vaccination? *This is a mandatory field. Has your child tested positive for COVID-19 in the last 12 weeks? Yes No If Yes, please specify the date of the positive test *This is a mandatory field. As Parent / Legal Guardian - I consent to my child receiving their 2nd dose of the COVID-19 vaccination: Yes No *This is a mandatory field. Name of Parent or Legal Guardian: You are here: Page 1 of 2