BHPRSD Survey: Vaccination Interest for Students and Staff

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The Black Horse Pike Regional School District is partnering with the Camden County Department of Health to offer vaccinations to students and staff at one or more of our high schools.

The Camden County Department of Health will be able to provide Moderna, J&J, or Pfizer first, second vaccination doses AND anyone who wants a vaccination "booster."

Details will be posted on our website and available at the schools. If you want to get vaccinated, please respond to this survey. For students under the age of consent, 18 years of age, you will need to have a parental consent form before being permitted to get vaccinated.

In order to secure the vaccinations on-site, we have to report our student/parent interest for the County Health Office to make a commitment to our School District. So, please respond to the survey if you are interested in the possibility of getting vaccinated. Thank you.

Check the box that applies to you. *

Staff member

Student

Parent

Required

School Attending or Working At *

Triton Regional

Highland Regional

Timber Creek Regional

C.A.R.E.

Other:

Preferred Phone Number (xxx-xxx-xxxx) *

Preferred email *

I am interested in getting vaccinated at the school by the Camden County Department of Health

Yes

Clear selection

First Name of person getting vaccinated

Last Name of person getting vaccinated

Birth date [mm/dd/yyyy]

Home Street Address

Home Town or City

Home Zip Code

If under the age of consent, list parent First Name

If under the age of consent, list parent Last Name

I have already received a COVID vaccine. *

Yes

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