COUNTY Please complete the form below and bring to the flu clinic SANDERS For any questions please call the Sanders County Health Department at 406-827-6931. MONTANA Please wear appropriate clothing (short sleeve shirts) to allow access to arm. I give my permission to receive a flu vaccine from the Sanders County Public Health Department. WASH YOUR HANDS, COVER YOUR COUGH, and GET YOUR FLU SHOT! Name: Date of birth: Sanders County Public Health Department "Drive Thru" Flu Clinic schedule - Mailing Address: All ages welcome! Phone number: NOXON PILGRIM CREEK PARK (AVISTA) 11 Pilgrim Creek Park Rd WEDNESDAY, OCT. 14th Signature: Date: Insurance/health coverage information. Medicare # 10:00 AM to 12:00 PM Medicare Supplemental Insurance name: - TROUT CREEK - TROUT CREEK PARK #2 Park Street Member ID # WEDNESDAY, OCT. 14th Health Insurance Company (BlueCross BlueShield, Allegiance, Tricare, United Health Care, etc) 2:00 PM to 4:00 PM Name: THOMPSON FALLS - COMMUNITY CENTER Member #: Group #: 410 Golf Street Company contact Phone #: WEDNESDAY, OCT 21st 2:00 PM to 4:00 PM Medicaid (HMK Plus) Member ID# Do not have health insurance coverage PLAINS - FAIRGROUNDS 30 River Road West THURSDAY, OCTOBER 15h 2:00 PM to 4:00 PM I authorize the Sanders County Public Health Department to enter my flu vaccine into the Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records that medical facilities/ providers will be able to see. HOT SPRINGS TOWN PARK Parent/guardian Signature: Corner of South Spring Street and Main Street WEDNESDAY, OCTOBER 28th from 2:00 PM to 4:00 PM Date: COUNTY Please complete the form below and bring to the flu clinic SANDERS For any questions please call the Sanders County Health Department at 406-827-6931. MONTANA Please wear appropriate clothing (short sleeve shirts) to allow access to arm. I give my permission to receive a flu vaccine from the Sanders County Public Health Department. WASH YOUR HANDS, COVER YOUR COUGH, and GET YOUR FLU SHOT! Name: Date of birth: Sanders County Public Health Department "Drive Thru" Flu Clinic schedule - Mailing Address: All ages welcome! Phone number: NOXON PILGRIM CREEK PARK (AVISTA) 11 Pilgrim Creek Park Rd WEDNESDAY, OCT. 14th Signature: Date: Insurance/health coverage information. Medicare # 10:00 AM to 12:00 PM Medicare Supplemental Insurance name: - TROUT CREEK - TROUT CREEK PARK #2 Park Street Member ID # WEDNESDAY, OCT. 14th Health Insurance Company (BlueCross BlueShield, Allegiance, Tricare, United Health Care, etc) 2:00 PM to 4:00 PM Name: THOMPSON FALLS - COMMUNITY CENTER Member #: Group #: 410 Golf Street Company contact Phone #: WEDNESDAY, OCT 21st 2:00 PM to 4:00 PM Medicaid (HMK Plus) Member ID# Do not have health insurance coverage PLAINS - FAIRGROUNDS 30 River Road West THURSDAY, OCTOBER 15h 2:00 PM to 4:00 PM I authorize the Sanders County Public Health Department to enter my flu vaccine into the Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records that medical facilities/ providers will be able to see. HOT SPRINGS TOWN PARK Parent/guardian Signature: Corner of South Spring Street and Main Street WEDNESDAY, OCTOBER 28th from 2:00 PM to 4:00 PM Date: