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Flu Shot Request Form
Location: Building 900 Cafeteria - outside, in front of Health Services lobby
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Student ID Number
*
Your answer
Phone Number
*
Your answer
I am in the following age group
*
7 - 18 years (parent/guardian consent required for ages 17 and under)
19 - 49 years
50 -59 years
60 - 64 years
65 + years
Desired Flu Shot date
*
Monday thru Thursday 11 am - 2pm (Starting September 25, 2023)
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/
DD
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Time
:
AM
PM
Preferred Flu shot
*
Regular Flu shot $2
Preservative free Flu Shot $20.00
Payment Option
*
Choose
Cash
Check
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