Pfizer Vaccine

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Pfizer Vaccine

Students 12 years of age and older are now eligible to receive the Pfizer vaccine. The Henderson County Health Department will be conducting the vaccine clinic. Please complete and submit this form if you are interested in your child receiving the Pfizer vaccine. If parent(s)/guardian(s) are interested in receiving the vaccine at the same time as the student, please complete form appropriately. If you express interest, you will be contacted with more detailed information.

Student's First and Last Name

Student's Date of Birth

Student's Grade Level

Is a parent(s)/guardian(s) within household interested in receiving vaccine at the same time as student?

Yes

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If answered yes to the above question: Please provide names of interested individuals below

Is there a certain time that works best to receive vaccine?

Morning

Afternoon

Evening

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Any questions?

Submit

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