LF Vaccine Clinic Interest Survey

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ACME Markets is again partnering with Little Flower to provide a COVID vaccine clinic on Thurs, 2/24/22. Students are strongly encouraged to vaccinate and/or get boosted in advance of important milestone spring events. Please fill out the survey below. Any siblings and family members are welcome to participate. The Clinic would run from 2pm to 8pm.

First Name *

Last Name *

Date of Birth *

YYYY

Street Address *

City *

State *

Zip Code

Best Phone Number *

Best Email *

Are you interested in receiving an initial COVID Vaccine? *

Yes

Are you interested in receiving a Booster COVID vaccine (Pfizer only if after 6 months) *

Yes

Are you interested in receiving a flu vaccine? *

Yes

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