Becoming a Volunteer
Time Off Form
Consent / Declination for Influenza Vaccination
Indicates required field
Do you have a SEVERE allergy to eggs or other vaccine components?
Have you ever had Guillain-Barre Syndrome within 6 weeks after a previous influenza vaccination?
I have received or will receive my vaccination at Baptist Health Lexington.
I have had my vaccination this year at another location.
I am not able to receive this vaccination due to the reason(s) identified above.
I will not be volunteering at Baptist Health Lexington during the period of October 1 through March 31.
Choose ONE from the Drop Down Menu.
If vaccinated at another location, please provide the location name and date of vaccination:
We MUST have this information if you had your flu shot anywhere else.
(859) 260-6670 (Adults)
(859) 639-8144 (Students)