Vigo County School Corporation student vaccine interest form

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The Vigo County School Corporation is investigating the possibility of holding COVID-19 vaccine clinics during the school day for interested students. We are trying to gauge interest in the clinic for planning purposes. This is NOT a sign-up sheet.

The clinic would provide the Pfizer vaccine, which is approved for ages 16 and up. The shot would be administered by school nursing staff and other qualified healthcare professionals.

Once a clinic is planned, any student under the age of 18 would need a parent/guardian consent form filled out before receiving the shot. The COVID-19 vaccine is not mandatory.

You should only fill out this form if you are interested in your student receiving the vaccine. Please fill out one form per interested student.

The Vigo County School Corporation has a history of facilitating vaccine clinics for vaccines appropriate for students, most recently in response to H1N1 flu and varicella (chicken pox) outbreaks.

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Yes, I am interested in my student receiving the Pfizer COVID-19 vaccine at a potential school-based clinic. My student is 16 years old or older and attends a VCSC high school. *

The above information is accurate.

Wymagane

My student attends *

Student last name *

Student first name *

Parent/guardian last name *

Parent/guardian first name *

Parent/guardian phone number *

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