Age 5-11 Vaccine Clinic Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

In our District’s ongoing support of the Covid-19 vaccination effort, we are planning to host a vaccination clinic for those students who are 5 to 11 years old using the Pfizer-BioNTech COVID-19 vaccine.

If you are interested in having your child receive the vaccine through the District, please complete the form below by 10/29. Completing this form will ensure we have enough vaccines for all children. This information will be kept confidential and will only be used in our efforts to secure enough vaccines.

Email *

Student Last Name *

Student First Name *

Student Age *

Clinic Participation *

I am the guardian of a child who is 5-11 years of age and am interested in participating in the MTLSD Vaccine Clinic.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Mt Lebanon Staff. Report Abuse

Forms