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順德幼兒園滿5足歲幼兒接種BNT疫苗意願調查
預定施打日期：111年6月7日
施打地點：青埔國小
需攜帶健保卡、意願書(5/30發回)及家長陪同
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幼兒就讀班別
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蘋果中班
綿羊大班
幼兒姓名
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Your answer
性別
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男
女
身分證字號
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Your answer
施打意願
*
由園方安排至國小集中接種(需有家長陪同)
自行安排到診所或醫院接種
謝謝，目前沒有意願安排接種
陪同家長姓名
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Your answer
行動電話
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Your answer
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