Student Vaccination Time Slot Sign Up

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Please complete this form once for each person (adult or student) you would like to receive the COVID-19 vaccination through the Pennsbury event scheduled for May 23rd, 2021. All students must be a least 12 years old on May 23, 2021. If you have multiple students/adults, you will be able to click "Submit another response" after you click "Submit". You will receive an email with a record of your submission.

Email *

Last Name of Person Receiving Vaccine *

First Name of Person Receiving Vaccine *

I would like to have my student or myself vaccinated at the event at Pennsbury High School on 5/23/2021. *

Yes, I would like to proceed to schedule a time slot for the appointment.

I no longer need to secure a time slot. (This will finish the Form for you)

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