Primary School Flu Vaccination 2025/26

Flu vaccination registration form. This vaccination is FREE for all children aged 2-17. Please ONLY complete this form if you wish to avail of this service. Upon registering, you will receive an email confirming your child's application.

What School does your child attend? *

What Class is your child in? *

Junior Infants
Senior Infants
First Class
Second Class
Third Class
Fourth Class
Fifth Class
Sixth Class

Teacher's Name *

School Flu Vaccine Consultation Form (NS Children)

The information requested is required to ensure the vaccine suitability and to record the details of your child's vaccination. This information is held securely in line with GDPR requirements.

PLEASE NOTE: For parents with more than 1 child in the school, you will need to fill in one form for each child. For the past number of years, the HSE has recommended free Flu Vaccinations for children. This is because children play a key role in the transmission of flu and may pose a threat to those who are at higher risk of complications from flu such as the elderly, those who are pregnant or other children with underlying conditions.

Please see HSE guidelines

https://www2.hse.ie/conditions/flu/childrens-flu-vaccine/

Part 1: Child's Personal Details

Child's First Name

Child's Middle Name

Child's Surname

Child's Date of Birth *

(This Vaccine is only suitable for children 2-17 years inclusive) *

GP Name *

GP Address *

Mother's Surname at Birth:

Sex at Birth *

Male
Female

Childs Ethnic or Cultural Background:

A. White

Irish
Irish Traveller
Roma
Any other White background

B. Black or Black Irish

African
Any other Black background

C. Asian or Asian Irish

Chinese
Indian/Pakistani/Bangladeshi
Any other Asian background

D. Other, including mixed background

Arab
Mixed, write in description
Other, write in description

Description

Prefer not to say

Child's Country of Birth

PPS Number *

Address *

Eircode

County *

Child's Address when they last had a vaccine, if different from above

Part 2: Parent/Guardian Personal Details

Parent/Legal Guardian Forename and Surname *

Daytime Phone Number: *

Mobile Phone Number:

Email: *

Part 3: Child's Medical Details

Has your child ever received the flu vaccine before? *

Has your child already had a flu vaccine since 1 September 2025 *

Has the child ever had a severe allergic reaction to anything including medication or vaccines? *

If yes, please provide details

Has your child needed an Intensive Care Unit (ICU) admission following an allergic reaction to eggs? *

Has your child been diagnosed with asthma? *

If yes to the previous question, does your child take regular steroids for their asthma and/or has your child ever been admitted to ICU/Critical Care for Asthma?

Does your child take aspirin/salicylates medication? *

Does your child have a severely weakened immune system due to disease or treatment? eg. leukaemia/lymphoma or high dose steroids or severe neutropenia *

Does your child live with anyone currently having treatment that severely affects their immune system? eg. someone who has had a bone marrow transplant? *

If yes, please provide details

Does your child take medication called combination checkpoint inhibitors eg ipilumumab plus nivolumab? *

Is your child known to have a condition causing a Cerebrospinal Fluid (CSF) leak and/or has your child had a recent cochlear implant? *

Does your child have an inherited metabolic disorder? If no skip to Part 4. *

Please note that some children with inherited metabolic disorders may not be able to get the Nasal flu vaccine (LAIV). Children with inherited metabolic disorders will usually be attending a specialist medical team. Please ask your child's specialist medical team whether your child should get the Nasal flu vaccine (LAIV) before you consent for the vaccine:

Have you discussed whether your child can get the Nasal flu vaccine (LAIV) with your child's specialist medical team?

If yes, has your child's specialist medical team confirmed that your child can get the Nasal flu vaccine (LAIV)?

Part 4: Immunisation Consent

Medical Consent: Please note only a parent or legal guardian can provide consent for a medical procedure for young people under 16 years of age. Young people aged 16 years or older are legally entitled to consent for themselves. If a young person aged 16 or 17 years old is unable to give informed consent then their parent or legal guardian can consent on their behalf. Read more about the HSE Consent Policy on the HSE website.

CONSENT TO VACCINATION: *

YES, I want my child to receive the flu nasal spray vaccination

Please tick the box above indicating that you consent (tick yes) for your child to receive the vaccination, and then sign this section.

By signing the below I confirm that:

• I have read and understand the accompanying vaccine information, including known side effects.

• I am authorised to give consent on behalf of the above named child.

(young people 16 years or older are legally entitled to consent for themselves).

• I understand that LAIV Nasal flu vaccine is not recommended during pregnancy.

Name: *

Signature

Clear

Date *

(Please tick): *

Parent
Legal Guardian
Self

Thanks for registering!

We appreciate you taking the time to share your childs details.

Have a great day!

Click here if you wish to submit another child

https://www.brandonvalepharmacy.ie/schools

Thanks for registering!

We appreciate you taking the time to share your childs details.

Have a great day!

Click here if you wish to submit another child

https://www.brandonvalepharmacy.ie/schools

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