VFC Program Distribution of Pediatric Vaccines 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the required fields marked with an asterisk (*). Start with the recipient's last name, first name, and mother’s maiden name. Ensure all entries are in capital letters for clarity.
3. Next, provide the date of birth in the specified format (Month/Day/Year) along with the mailing address, city, state (NM), zip code, and contact numbers.
4. Indicate the sex of the recipient and complete the race and ethnicity sections as applicable. If you wish to receive vaccine reminders, check the consent box.
5. Fill out insurance information accurately. Select from Medicaid options or indicate if there is no insurance. Provide necessary IDs where required.
6. Answer all medical screening questions truthfully. If unsure about any question, consult your healthcare provider for clarification.
7. Finally, review your entries for accuracy before signing at the bottom of the form. Ensure that you print your name and include the date of signing.

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