COVID 19 Vaccination Clinic

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

We are hoping to hold a vaccination clinic the week of December 15th or 22nd. If you are interested attending our vaccination clinic, please indicate that below. Please note, this is VOLUNTARY. At this moment, Northwood is NOT requiring vaccinations to attend school.

Parent Name *

Parent Cell Phone *

Would you like to receive the COVID 19 vaccination at Northwood Academy? (Please note this is reserved for Northwood Parents/students and any non Northwood siblings living in the household) *

Yes

How many adults in your household would like to receive the COVID 19 vaccination?

How many children (over the age of five years old and living in your household) would you like to receive the COVID 19 vaccination?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Northwood Academy Charter School. Report Abuse

Forms