Student Vaccination Survey

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Champion Local Schools in conjunction with Champion Discount Pharmacy will be holding a vaccination clinic for students between the ages of 5 and 11. Please fill out this survey ONLY if you would like to have your child vaccinated with the Covid-19 Pfizer-BioTech vaccine at this clinic. This survey is only to assess whether there is enough interest for us to set up a vaccination clinic at Champion Schools. Please complete the survey by Friday, November 12th at 4:00 P.M. You must fill out a survey for each child you would like to attend the vaccination clinic.

Parent/Guardian Name *

Parent Email Address *

Name of Student to be vaccinated? *

Age of student as of today? *

Would you like to have your child vaccinated at Champion Schools during the school day? *

Yes

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