COVID-19 Community Vaccination Interest Survey (includes children age 12 and over)
Please complete the following form to assist the Williams Valley School District in identifying community members including students (age 12 and over with parent permission) who are interested in receiving a COVID-19 vaccination on the district campus.

People indicating interest will be contacted as vaccine appointments become available.
Please contact Dr. Best at with any questions. We need a minimum of 25 people to host the vaccination clinic.
Email *
Email *
Persons interested in the vaccine - Please respond in the following format: Last Name, First Name *
Phone Number (include area code) *
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