Lenawee County, MI · Lenawee County
Authorization for Immunization of Minors
Parents or legal guardians use this form to authorize adults to accompany a child to the county immunization clinic and consent to vaccines.
At a glance
- Issued by
- City of Lenawee County · Lenawee County, Lenawee County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- lenawee.mi.us
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form lets a biological parent or legal guardian authorize named adults to accompany a child to the immunization clinic, complete screening and billing paperwork, and sign for vaccines due at the visit unless declined in writing. It asks for the child’s details, authorized adults’ names and contact information, the signer’s information, insurance details, and any vaccines being declined. Legal guardianship requires written proof to be attached.
Who needs it
A biological parent or legal guardian uses this form when authorizing adults to accompany a child to the immunization clinic and sign for vaccines.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This form is signed and dated without a notary; legal guardians must attach written proof of guardianship.
How to submit this form
- 1
Download the Form
Download the Authorization for Immunization of Minors PDF.
- 2
Complete the Authorization
Enter the child’s information, authorized adults’ details, signer information, insurance details, and any vaccines being declined.
- 3
Gather Required Attachments
If signing as a legal guardian, attach written proof of guardianship. Attach a copy of the insurance card if applicable.
- 4
Submit to the County
Submit the completed form to the county department named on the form; check the county website for current contact details.
Frequently asked questions
- Who can authorize an adult to accompany a child?
- The form is for a child’s biological parent or legal guardian to name adults who may accompany the child to the immunization clinic.
- What information does the authorization request?
- It requests the child’s name and birth date, authorized adults’ names and contact details, the signer’s information, insurance details, and any vaccines being declined.
- Do I need a notary for the Authorization for Immunization of Minors?
- No. The form is signed and dated without a notary. A legal guardian must attach written proof of guardianship.
- How do I submit the authorization?
- Submit it to the county department named on the form; check the county website for current contact details.