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DONOT COMPLETE IF YOU DO NOT WANT YOUR CHILDVACCINATED20242025 School Based Influenza Vaccine Consent Form Thomas County Health Department Section 1: Information about Student to Receive Influenza Vaccine (please print) STUDENTS NAME (Last)(First)(M.I.)STUDENTS DATE OF BIRTH (mm/dd/yyyy)STUDENTS AGEGENDER:ETHNICITY (Please Circle)RACE (Please Circle) African American, White, Hispanic or Latino, American Indian, Asian, Alaska Native, Native Hawaiian, Other Pacific Islander,
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