NHS COVID Vaccine REGISTRATION FORM

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Northville Public Schools, in coordination with the Wayne County Health Department, is hosting a Pfizer Vaccine Site at Northville High School (NHS) on Saturday, May 22, 2021 (note you will automatically be scheduled for the second dose three weeks later on Saturday, June 12, 2021 at NHS).

Please register ALL individuals ages 12 and up in your household that will receive the Pfizer COVID-19 Vaccine on May 22nd at NHS. You will be required to select either AM or PM for your vaccination window, allowing us to plan accordingly. Students under 18 must have a parent present in order to receive the vaccination. PLEASE ONLY SUBMIT THIS REGISTRATION FORM ONE TIME for all members within your household.

Thank you for signing up for the Pfizer COVID-19 Vaccine on Saturday, May 22, 2021 at Northville High School.

Email *

FIRST NAME of person completing this vaccine registration form (follow up information will be sent to this person at the identified email address above) *

LAST NAME of person completing this vaccine registration form *

PHONE NUMBER of person completing this vaccine registration form *

I am a: *

Parent/Guardian of Current Students Attending NPS

NPS Community Member With Students Attending Schools Outside of NPS

NPS Community Member With No School Age Children

Surrounding Area Community Member with or without school age children

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