Student Vaccine Clinic
PLEASE FILL OUT THIS SURVEY ONLY IF YOU WISH TO HAVE YOUR CHILD(REN) VACCINATED. PLEASE FILL OUT ONE FORM PER CHILD AGES 12 AND OVER.

Pediatric Associates of Kingston will be providing a COVID vaccine clinic in the Northwest Area Gymnasium. As a public service to our community this clinic will be open to our students and families on Thursday, May 27th, from 3-6PM. The second Pfizer vaccine will be offered Thursday, June 17th from 3-6 PM. Please note that the Northwest Area School District is in no way sanctioning the vaccine or the clinic, but rather providing a location for administration of the vaccine. As the Northwest Area School District is not providing the vaccine or any healthcare services, the District cannot be held liable for any adverse reactions or related complications.

Pediatric Associates of Kingston will be offering the Pfizer vaccine that has been approved for ages 12 and older. Parents must be present for any current student of Northwest to receive the vaccine, regardless of the student’s age. In order to help Pediatric Associates in this process, we are asking our families to fill out the survey attached to this message. The survey will also be uploaded to our website. If you do not have an internet connection please call the school at 570-542-4126 x5006 to express your interest. Please contact your healthcare provider if you have any questions regarding the Pfizer vaccine.
Email *
Is your child a Northwest Area student? *
Is your child 12 years of age or older? *
Do you wish to have the child listed on this form vaccinated? *
If additional doses become available, would you wish to have any adult members of the household vaccinated? *
If you answered "Yes" to the previous question, how many adults in your household would be interested in receiving the vaccine? If you answered "NO" please enter 0. *
Student First Name *
Student Last Name *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Contact Number *
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