UPMC Student Vaccination Clinic Request
For the Charleroi Area School District Vaccine Clinic on December 10th, 2021 3-5pm in the Aux Gym
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What school are you attending? *
First Name *
Last Name *
Middle Name *
If you meet the CDC guidelines for booster vaccine and you are 18 or older, which vaccine would you prefer to have? *
Date of Birth *
MM
/
DD
/
YYYY
Legal Sex *
Street Address *
City *
County *
State *
Zip Code *
Email Address *
Phone Number *
Parent/Guardian Name (Only if child is under 18 years of age)
Parent Contact Number
Relationship to Patient
Have you participated in a COVID-19 vaccine trial *
Do you have a history of anaphylaxis with vaccines - that is a severe allergy requiring rescue medications to other vaccines or injectable therapies? (Note: this does not include a history of allergies, including food, environmental or oral medications) *
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