COVID Vaccine Clinic Interest

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please use this form to provide us information for the COVID vaccine clinic at Cathedral High School. We will correspond with Community Health Network to create appointment slots. The first clinic will be on Thursday June 3rd from 2-5. The second clinic will be on Thursday June 24th from 2-5. This is for anyone that is 12 years old and older. Parents must accompany any students that are between 12-17 years of age.

What is your email address? *

What is your cell phone number? XXX-XXX-XXXX *

How would you prefer us to contact you? *

Phone call

Text

Other:

Please list the first and last name of each family member (12 years old and older) that will be receiving the COVID vaccine at Cathedral at the first clinic - June 3rd from 2-5pm. Last name, first name. *

Please list the first and last name of each family member (12 years old and older) that will be receiving the COVID vaccine at the second clinic - June 24th from 2-5pm. Last name, first name. *

What time slot would you prefer for each clinic? *

2:00-3:00

3:00-4:00

4:00-4:30

First clinic June 3rd

Second Clinic June 24th

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Cathedral High School. Report Abuse

Forms