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H-F 2021 Vaccination Registration Form
Please complete and submit the form below by 9 p.m. on Wednesday, Oct. 6, in order to receive vaccines at H-F's Performing Arts Center on FRIDAY, OCT. 8, 7 A.M.-3:30 P.M.
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Email
*
Your email
LAST NAME OF PERSON RECEIVING VACCINE:
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Your answer
FIRST NAME OF PERSON RECEIVING VACCINE:
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Your answer
DATE OF BIRTH:
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MM
/
DD
/
YYYY
IF H-F STUDENT, PLEASE PROVIDE STUDENT ID NUMBER HERE:
Your answer
SELECT ALL VACCINES YOU ARE INTERESTED IN RECEIVING ON 10/8/21:
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Pfizer COVID-19 — 1st or 2nd Dose — FREE (Insurance Card Optional)
Flu Vaccine (2021-2022) — Insurance Card or Payment Required
Meningococcal — Insurance Card or Payment Required
Tdap— Insurance Card or Payment Required
MMR— Insurance Card or Payment Required
Hepatitis B— Insurance Card or Payment Required
Pneumococcal— Insurance Card or Payment Required
Shingles— Insurance Card or Payment Required
Human Papillomavirus (HPV - Gardasil) — Insurance Card or Payment Required
Other:
Required
SELECT YOUR INSURANCE PLAN:
State Insurance
Private PPO Plan
Private HMO Plan
No Insurance (Insurance is not required for the Pfizer COVID-19 Vaccine; payment for other vaccines can be made by check or credit card at time of service.)
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Signed consent form must be brought to vaccination site on 10/8. Copy and paste link below to download the form:
https://drive.google.com/file/d/1ro6Q7rqFIYKZ0wQxLt6hFRRsY_K5YpS5/view?usp=sharing
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