Student COVID Vaccination Survey

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McKinley High School is looking into the possibility of hosting a pop up COVID vaccination clinic for all eligible MHS students (16 years and older) and their families. If you are 16 or 17, a parent must accompany you to your vaccination appointment. Each person that gets vaccinated will receive the Pfizer shot and will need to return 3 weeks later to receive their follow up vaccine. Exact dates and further details are still being finalized but May 15 and June 5 have been identifid as potential dates. If you and/or your family are interested in receiving a vaccine, please fill out this form.

Student's Last Name *

Student's First Name *

COVID Vaccination *

I am 16 years or older and interested in receiving the vaccine.

Both my family and I are interested in receiving the vaccine.

I am under the age of 16, but my family is interested in receiving the vaccine.

Total number of people interested in receiving the vaccine. Must be 16 years or older. Count yourself as part of this total. *

Email Address *

Phone Number *

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