Adolescent COVID-19 Vaccination Consent Form

To ensure a safe vaccination process, a parent or legal guardian must be present when their child under 18 years of age gets vaccinated.

In the case that a parent or legal guardian is unable to accompany the child, Korea Disease Control and Prevention Agency provides this form to receive consent for the child to be vaccinated at a medical facility alone.

If you consent to have your child vaccinated without your presence, please fill out a COVID-19 vaccination report and this consent form and have your child submit them to a medical facility for vaccination.

* Note: The COVID-19 vaccination report and this consent form must be completed by a parent or legal guardian. Please download the two documents at KDCA’s official website (ncv.kdca.go.kr)

Please check the vaccine to be provided to your child.

□ Pfizer-BioNTech COVID-19 Vaccine (Comirnaty)

* Comirnaty 0.1mg/mL (5 through 11 years of age) will be given to children in that age group.

2. Did you fill out the COVID-19 vaccination report for your child?  Yes □  / No □

3. Please inform in advance that your child must wait for 15~30 minutes at the medical facility after vaccination in case of an adverse reaction.   Yes □

4. Please guide your child to avoid vigorous exercise and activities for a week after your child has been vaccinated and thoroughly observe her/his health condition.   Yes □

5. Please put an accurate phone number that a health provider can contact you at to explain side effects after vaccination and to check if you will give consent for your child to be vaccinated without your presence.

(Phone number:                           )

※ Note: Vaccination can be delayed upon the health condition of the person being vaccinated and a preliminary medical examination of her/his doctor on the day of vaccination.

Name of Child (Last, First, Middle):

Relationship to Child:

Name of Parent or Legal Guardian (Last, First, Middle):

Date (Day/Month/Year):

Name of Parent or Legal Guardian:          (Signature)