Covid-19 Vaccine Clinic at Salem City Schools.
Please complete this survey only if you would like your Salem City School's student/s ages 12 and up to receive the Covid-19 vaccination on Friday, May 21st at school. A follow up clinic for the second dose will be held on Friday, June 11th. Please complete this form even if you already signed up previously.

Please complete a Vaccination Registration Form for each student ages 12 and up that will be receiving a vaccination. Paper forms may also be picked up in the JH/HS office from 7:00 am- 3:15 pm.

Pfizer Vaccination Information:
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Pfizer-BioNTech.html

Vaccination Registration Form:
https://geweb.azureedge.net/-/media/Files/pharmacy/COVID-19-Vaccine-Administration-Form-for-Stores-04-28-21.ashx?la=en&hash=F53DC5F9D1D27892F43902BF8FC81E7A202DBE0B

Giant Eagle Clinic:
https://drive.google.com/file/d/11wHMgSGGfCPlVXDDlPQs4H-NK4BO2_Bx/view?usp=sharing
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Email *
First child's name (first and last) *
First child's age as of May 21, 2021 *
Required
Second child's name (first and last)
Second child's age as of May 21, 2021
Third child's name (first and last)
Third child's age as of May 21, 2021
Fourth child's name (first and last)
Fourth child's age as of May 21, 2021
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