TriRivers Career Center Student Immunization Sign-Up
Hi Parents and Students of TriRivers Career Center,

Please fill in the form below to sign up for student immunization.

Our Student Immunization Clinic will be on Thursday, June 8th from 10am to 2pm TRCC gym. We will be offering Hepatitis B, Tdap, and Meningicoccal vaccines as recommended by the CDC and school requirements.

We are collecting your insurance information to pre-verify your coverage and any cost prior to the clinic.

Students under the age of 13 will require a prescription to be vaccinated.

Students under the age of 18 will require a parent to be present during immunization.

Please sign up by June 2nd.

Thank you and we look forward to seeing you at our Student Immunization Clinic!

Megan Kappes, RPh
Meijer Clinical Pharmacist Specialist


Christine Pemberton, RN Health Services Coordinator
TriRivers Career Center
Phone: 740-389-8519
What is the student's full name? *
What is the student's date of birth? *
What is the best phone number to contact the parent of the student?
What immunizations does the student intend to receive? *
Example Insurance Cards
What is the student's pharmacy benefits insurance company? *
What is the RxBin on the student's insurance card? *
What is the PCN on the student's insurance card? *
What is the ID# on the student's insurance card? *
What is the RxGroup on the student's insurance card? *
If you have questions or comments, please enter them here. Thanks!
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