Pediatric COVID-19 Vaccination Information

Thank you for your interest in the COVID-19 vaccination.

For patients who are between the ages of 5 – 12, please complete the form below to register to receive the vaccine for COVID-19.

Documentation required for minors (ages 5-12) receiving the Covid-19 vaccine:

  • Parents/Legal Guardians bringing minor must present a valid form of ID (driver’s license) at the time of vaccine
  • Notarized written consent in cases where the parent/guardian is not present at the time of vaccination
    • Parents may also call 502-SHOT to give verbal consent before vaccination if unable to provide written documentation
  • Notarized Affidavit (link below)
  • Letter of written consent by Children’s Division, or designee, for all minors under the care of Department of Social Services/Division of Youth Services
  • Documentation of proof if pregnant/married/emancipated minor
  • Documentation from person/entities, such as governmental or nonprofit agency, if the youth is homeless

Click the link below to access the Affidavit form. The form can be completed online, then printed.

Minor Consent Form

Pediatric Registration Form

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By providing my phone number and/or email address, I opt-in to receive SMS messages and/or Emails from Freeman Health System.

Pediatric Vaccine Clinic Location: Freeman Business Center – 1221 McIntosh, Joplin, MO

If you have any questions, please call 417-502-SHOT (7468).