Pediatric COVID-19 Vaccine 2nd Dose Interest Form
This interest form is for the second dose of the COVID-19 vaccine for children ages 5-11. Also, if you would like to have your child receive their initial dose of the vaccine, please complete the form below.

After you submit this form, please click the corresponding school link to schedule your child's appointment for December 3, 2021.

*Note: Parents/Guardians of children ages 5-11 must be present at the time of the vaccination.
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Student's Legal Name *
Parent/Guardian Name *
Student School *
Do you wish for your child to receive the Pfizer COVID-19 vaccine on December 3, 2021? *
Clicking "no" will end the survey
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