Affiant, __________________________, being first duly affirmed states as follows:
1) Affiant has recommended that the child named ________________________
At age _______ Years old be vaccinated with ___________________________ _______________________________ ____________________________ _______________________________ ____________________________ _________________________ vaccine(s).
2) Should parents permit said child be vaccinated, affiant shall provide them with complete information about the vaccine(s), including lot number(s), expiration date(s), and manufacturer(s).
3) Affiant agrees, by weight of promisory note, to pay twenty five (25%) of all costs, medical and other, for the care of said child should any injury result from the vaccine(s).
Affiant further sayeth naught.
Subscribed in my presence this ________ Day of _________.
Affiant __________________________________ Date ____________
Notary __________________________________ Date ____________