COVID Vaccine Interest Form

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COVID Vaccine Interest Form

Jacksonville Medical is offering the COVID 19 vaccine to teens 16 and up. an insurance card is requested but not required. This form is to gauge parent interest in this opportunity for our scholars. This is not a commitment form.

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* Indicates required question

Jacksonville Medical Clinic is offering the COVID vaccine to teens 16 and up. Would you be interested in your scholar receiving the vaccine? *

Yes

No

Do you have an insurance card? (Not Required) *

Yes

No

Submit

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