Is your child an LCPS Student, 12 years of age or older, and are you interested in them receiving a COVID-19 Vaccination?
Do you have a child who is an LCPS student and 12 years of age or older?  Are you interested in your child receiving the COVID-19 vaccine?  If so, please answer the questions in this survey.  Smith's Pharmacy will be conducting the clinic at Central High School on Wednesday, June 9 from 9 a.m. - 1 p.m. You will be called soon to schedule an appointment if you complete this survey.   The second dose will be scheduled at the clinic. The Pfizer vaccine is what will be administered. If your child has ever had an allergic reaction to an injection of any type, they will not be able to receive the COVD-19 Vaccine at this clinic.
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Student's first and middle name as it appears on their birth certificate: *
Student's last name as it appears on their birth certificate: *
Student's current age: *
Student's date of birth: *
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Parent/Legal Guardian's first name: *
Parent/Legal Guardian's last name: *
Parent/Legal Guardian's email address: *
Parent/Legal Guardian's phone or cell phone number: *
I am interested in having my child receive the COVID-19 vaccine.   *
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