2021 Baldwyn COVID Vaccine Sign-Up
Please complete this form if you would like to receive the COVID-19 vaccine on Wednesday, September 22, 2021 from 2-5 p.m. at Baldwyn High School auditorium. The event is hosted by Booneville's Baptist Memorial Hospital and all vaccines will be provided and administered by their certified staff. DEADLINE to sign up is September 17, 2021. Please note the following:
1. ANYONE can sign up to participate (except persons under age 12)
2. Persons ages 18 and up will receive the Moderna vaccine.
3. Persons ages 12-17 will receive Pfizer vaccine.
4. An ID will be required on site to participate.
5. Any persons ages 12-17 will have to have a parent present to participate.
6. NO proof of insurance is required to participate.
7. MUST sign up through this form by 9.17.21 to be eligible to participate on 9.22.21.
Name (legal First and Last)
Date of birth
Current age (on 9.22.21)
Mailing address (house number, street name/number, city, state, zip code)
Contact phone number (one that is in service please)
I understand that I will be participating in a FREE COVID-19 vaccination on 9.22.21 administered by Booneville Baptist Memorial Hospital staff. I will bring an ID. If a minor (12-17), I will have a legal guardian/parent present.
I need further assistance to participate.
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This form was created inside of Baldwyn School District.