COVID-19 Vaccine Interest for Children Ages 5-11 Contact information
Pending FDA and CDC approval, Dorchester County Health Department will be holding Pfizer COVID-19 vaccine clinics for eligible children between the ages of 5-11 in November 2021. To indicate interest in getting your child vaccinated against COVID-19, please submit this online form. Children MUST HAVE the consent of their parent or guardian in order to receive the vaccine.
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Child - Name (First and Last) *
Child - Date of Birth (mm/dd/yyyy) *
Child - Age *
Child - Gender
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Parent/Guardian Name: (First and Last) *
Parent/Guardian Contact Information: Telephone Number *
Contact Information: Email
Demographics: Race *
Demographics: Ethnicity
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Demographics: County You Currently Live In *
Demographics: Street Address *
Health: Does your child have any underlying medical conditions? *
Health: Who is your child's primary care provider? *
Scheduling Considerations: What day of the week would you prefer to have an appointment for your child? *
Scheduling Considerations: What time of day would prefer to have an appointment for your child? *
Scheduling Considerations: Would you like DCHD Immunization staff to pre-register you for an appointment slot based on the scheduling preferences you listed above? *
Special Considerations: If you have multiple family members interested in getting vaccinated, please list the first name, last name and DOB (mm/dd/yyyy) for each family member below *
Special Considerations: Do you or your child require any accommodations for a disability or language services? If so, provide additional details below. *
Additional Questions or Concerns? *
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