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

Please slow down and accurately type in the proper information.

NOTE - this vaccine clinic is only for those that are 12 and older

If this is not your 3rd dose, the second dose will be administered 21 days later on February 1st at the same time your first dose was booked for. Please do not sign up for first dose, if you cannot commit to the second dose appointment. Thank you for understanding