COVID-19 Vaccine Interest Survey

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This survey is to see if you would be interested in allowing your student to receive the Covid Vaccine during parent teacher conference day October 12th at the Northampton High School. A parent or guardian must be present with the student during the shot and the 15 minute evaluation afterwards. This is only available for students 12-18 years of age. Answers due by Friday October 8th

Interested (If no, no other information is needed to submit the survey) (If yes, fill out the rest of the form and then submit) *

Yes

Within Age Range 12-18 (if no they do not qualify, end survey and submit) *

Yes

Child's Name(s)

Child's School(s)

Best Parental Contact - Phone Number

Submit

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