COVID-19 Vaccination Interest Form
The Johnson County School District is checking interest from parents and students to potentially  offer a COVID-19 vaccine clinic to any student 12 years old and up during the school day.   Remember that any students/staff who are fully vaccinated are not required to quarantine following exposure if asymptomatic.  Please complete the attached form by Friday, September 3 to register your child for the vaccine.  Once dates are set, you will be contacted with further instructions.  
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Student Name *
Parent/Guardian Name *
School *
Required
Birthday *
MM
/
DD
/
YYYY
Current Age *
Phone Number *
I want my child to receive the COVID-19 vaccination that will be administered by the Johnson County Health Department. *
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