Community Vaccination Clinic at Claremont High School - September 9, 2021
CUSD is hosting a vaccination clinic at Claremont High School on September 9, 2021 from 2:00 to 6:00 PM. Anyone with a birthday on or before September 9, 2009, is eligible for this no-cost Pfizer COVID-19 vaccine. One form must be completed for each person getting a vaccine.
Sign in to Google to save your progress. Learn more
Email *
First and last name of person receiving vaccine *
Date of Birth *
MM
/
DD
/
YYYY
Select One *
Name of parent/guardian or answer 'self' (required for minors) *
Phone Number *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of cusd.claremont.edu. Report Abuse