COVID-19 Vaccine Scheduler
Welcome to the COVID-19 Vaccination online reservation system.

Chesapeake Public Schools will host COVID-19 vaccination clinics at our high schools the week of May 24, 2021. We have partnered with Rite Aid and the Chesapeake Health Department to provide this voluntary opportunity for our community. First doses of the Pfizer COVID-19 Vaccine will be available for students (ages 12 and older with a parent or guardian present), parents, and employees.

There is no charge to the patient or the district for the COVID-19 vaccine.
Name *
Please identify the individual who will receive the first dose of the COVID-19 vaccine (Pfizer).
The individual listed above is a *
Please pick one
Student ID
Please list a Kronos Number is you are an employee. Leave this field blank if you are the family member of a student.
Parent/Guardian Name *
Please provide a parental contact name for the individual receiving the vaccination if they are a minor. Adults completing this reservation can type "N/A".
Contact Phone Number *
Please provide a phone number. If the individual receiving the vaccination is a minor, please list the phone number for their parent/guardian.
Email Address *
Please provide an email address. If the individual receiving the vaccination is a minor, please list an email address for their parent/guardian.
School
If you are a student, please identify your school
Choose a Clinic
Next
Never submit passwords through Google Forms.
This form was created inside of Chesapeake Public Schools. Report Abuse