May 14th Covid Vaccine Clinic at Pomperaug High School - Nonnewaug Students, 16-18 Years Old

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PLEASE COMPLETE THIS FORM FOR EACH STUDENT INTERESTED IN RECEIVING THE VACCINE.

On May14th, from 1-4pm, the Pfizer Covid Vaccine will be available at Pomperaug High School for Nonnewaug High School students ages 16-18. After receiving the first dose, the second dose will be scheduled for three weeks later. Please note that students under the age of 18 must be accompanied by their parents or guardian in order to receive the vaccine.

First and last name of the student interested in receiving the Covid vaccine *

Email address of the student *

Age of the student (Please remember that students under the age of 18 will need to be accompanied by a parent or guardian in order to receive the vaccine) *

Parent or guardian's first and last name *

Parent or guardian's email address *

Parent or guardian's phone number *

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