German Township Volunteer Fire Dept.
8400 St. Wendel Road Voice 812-963-9077
Evansville, IN 47720 FAX 812-963-5622
E-Mail - GermanFD@aol.com http://www.germanfiredept.org
Hepatitis B Vaccination Form
Read and Return to the Safety Officer
German Township Volunteer Fire Dept holds the health and safety of its members as one of our top priorities. In
doing so, the fire department offers the vaccination against Hepatitis B free of charge to all members. Members do
not have to accept the vaccination but must sign a waiver releasing the fire department from liability if they would
happen to contract this illness. If you have already received this series of 3 vaccinations, you do not need to get
them again, but instead get me a copy of when you had the vaccinations. Please fill out the bottom portion of this
page and return back to me. If you have any questions, please feel free to contact me.
________ I have already received the vaccination and I will get you the dates that they were done.
________ No, I do not wish to receive the Hepatitis B Vaccination and I release German Township Volunteer
Fire Department and anybody directly involved and indirectly involved with German Township Volunteer Fire
Department from any liability from my doing so.
________ Yes, I wish to receive the Hepatitis B Vaccination.
Member’s Name______________________ Member’s Signature________________________________
(only required if refusing the Hepatitis B Vaccination)
Office Use Only
Series One Series Two Series Three
Person Administering Vaccination
Date of Vaccination
I hereby authorize MEC to administer the series of Hepatitis shots to the above named individual and bill
German Township Volunteer Fire Department for the charges associated with the vaccinations. Billing address
is 8400 St. Wendel Rd., Evansville IN 47725. Any questions please contact the Safety Officer, 812-963-9077.