COVID-19 Vaccine Interest for Children Ages 5-11 Contact information
Pending FDA and CDC approval, Dorchester County Health Department will be holding Pfizer COVID-19 vaccine clinics for eligible children between the ages of 5-11 in November 2021. To indicate interest in getting your child vaccinated against COVID-19, please submit this online form. Children MUST HAVE the consent of their parent or guardian in order to receive the vaccine.
Sign in to Google to save your progress. Learn more
Child - Name (First and Last) *
Child - Date of Birth (mm/dd/yyyy) *
Child - Age *
Child - Gender
Clear selection
Parent/Guardian Name: (First and Last) *
Parent/Guardian Contact Information: Telephone Number *
Contact Information: Email
Demographics: Race *
Demographics: Ethnicity
Clear selection
Demographics: County You Currently Live In *
Demographics:  Street Address *
Health: Does your child have any underlying medical conditions? *
Health: Who is your child's primary care provider? *
Scheduling Considerations: What day of the week would you prefer to have an appointment for your child? *
Scheduling Considerations: What time of day would prefer to have an appointment for your child? *
Scheduling Considerations: Would you like DCHD Immunization staff to pre-register you for an appointment slot based on the scheduling preferences you listed above? *
Special Considerations: If you have multiple family members interested in getting vaccinated, please list the first name, last name and DOB (mm/dd/yyyy) for each family member below *
Special Considerations: Do you or your child require any accommodations for a disability or language services? If so, provide additional details below. *
Additional Questions or Concerns? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of Maryland. Report Abuse
Google Forms