Vaccination for Students-5 to 11 Years Old Interest Form

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Pfizer’s COVID-19 vaccine for 5 to 11-year-olds is expected to be authorized for emergency use in the coming days. MCPS is partnering with the county’s Department of Health and Human Services and Holy Cross Hospital to offer a number of free vaccination clinics for children at schools and county sites once the vaccine is available.
Please take this opportunity to let us know your interest in having your child vaccinated.

Do you intend to have your 5 to 11 year old child receive the COVID-19 vaccine? *

If Yes, which of the following locations would you consider taking your (5 to 11) child for vaccination (check all that apply):

Pediatrician, family provider or School Based Health & Wellness Center (if enrolled in this program)

Pharmacy or grocery store

Urgent care or other community provider

Public health clinic at community site

Temporary clinic at a school site

Temporary clinic at a community site

All of the above

If No or Undecided, are there specific reasons for why you may not have your 5 to 11 year old vaccinated? Please check all that apply.

Health questions about the vaccine

Child health risks

Religious beliefs

Difficulty finding time (e.g., Unable to get time off work when child is out of school)

Difficulty getting to a location offering vaccinations

Other

If you selected other, please list other reasons:

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