This form must be filled out by Parent, Surrogate or Guardian.

Please slow down and accurately type in the proper information.

NOTE - this vaccine series is only for those that are 5 to 11 years of age

If you are booking your first dose, the second dose appt will be 28 days later on March 1st at the same appt. time your first dose was booked for. (we backed it up for a week since 21 days falls on Feb break) Please do not sign up if you cannot commit to the second dose appt. Thank you.