DA Vaccination Clinic Interest Survey

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Delaware Academy is working with Public Health to host a Pfizer vaccination clinic for students aged 16-18 during the month of June. However, we must first establish interest in our community. Please complete this survey if you would be interested in accessing the vaccination for your child(ren) at our campus, by Friday 5/21. This is not scheduled yet. Please do not cancel any current appointments. If there is enough interest to move forward, more information will be provided. Responding to this survey DOES NOT commit you or your child to receiving the vaccination.

Email *

Parent/Guardian Name *

I am interested in a Pfizer vaccination clinic located at Delaware Academy *

Yes

How many children do you have, between the ages of 16-18 who you are seeking the vaccination for? *

What time of day would you prefer the clinic be held? (Please check all that apply) *

During the school day (12:00-3:00)

After school hours (3:00-5:00)

Evening hours (5:00-7:00)

Required

The following could be options to establish parent/guardian consent for the vaccination. Please check those you are willing to provide: *

I will personally accompany my child to the clinic to provide consent

I will sign a consent form that my child will bring to the clinic in my absence

Required

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