Students Age 16 to 18 Going to Mass Vaccination Site at SUNY Potsdam Without a Parent/Guardian

The Mass Vaccination site at SUNY Potsdam has a new process for persons who are 16 to 18 years of age, if you are NOT going to be accompanied by a parent or legal guardian.

Upon arrival at the vaccination pod, you will be asked to provide a phone number to reach your parent or guardian at that time.  You should alert them to your appointment time and that this call will come from a phone number that may not be easily identifiable.   

They gave us the attached form last week.  They would like this completed form printed off OR they will accept for the student to bring a paper copy of an email from a parent or legal guardian with his or her first and last name, and a message indicating consent for NYS Department of Health to give the student the vaccine and any treatment if there is adverse reaction to the vaccination on site.  See sample communication below.  They are also asking for that to include a photo/image of some form of parental/guardian identification as shown below. They will not keep the paper copy at the site. 


As a parent/guardian of STUDENT NAME, I, “PARENT/GUARDIAN NAME” give NYS Department of Health, consent for a COVID-19 vaccination and any treatment if there is an adverse reaction.  A form of ID is below and I can be reached via phone at “PHONE NUMBER.”

If you have any questions, please contact me.
Kelly Chezum,
VP for External Relations

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