CWCTC Pfizer Covid-19 Vaccine Clinic

CWCTC, in collaboration with Giant Eagle, will be offering a COVID-19 vaccination clinic to students age 16+ and their families.

The first dose of the Pfizer vaccine will be administered at CWCTC on Thursday, May 6th.
The second dose will take place on Thursday, May 27.

All those interested in receiving the vaccine must complete this pre-registration form by Wednesday May 5.

Vaccine administration times will be available during school hours. We will be able to provide more specific times based on the outcome of this pre-registration. All students under the age of 18 will require additional signed consent on their Giant Eagle consent forms. All students under the age of 18 must turn in completed Giant Eagle consent forms to the nurse by Wednesday 5/5/21. These forms will be made available on our website or students can get a copy from Ms. Rolka, in the First Aid room. More info will be available on our website: www.cwctc.org
Last name *
First name *
Date of Birth *
MM
/
DD
/
YYYY
Please choose one *
*Students only: Parent/Legal Guardian name:
*Students only: Program
*Students only:
Clear selection
*Students only: Attending school:
Clear selection
Phone number: *
Email:
Submit
Never submit passwords through Google Forms.
This form was created inside of Central Westmoreland CTC. Report Abuse