STUDENT PFIZER VACCINE SIGN-UP for 12 years of age and over.
Washington County Health Department is planning a Pfizer COVID-19 vaccine clinic for youth 12 and over.  Please fill out this form to help with the planning. If you filled out the earlier form for 16 and over and have changed your mind to want the vaccine, please fill this form out.
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PFIZER COVID-19 VACCINE INFORMATION
Parent First Name *
Parent Last Name *
I prefer to be notified by: *
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Please enter contact information: *
Student 1 First Name *
Student 1 Last Name *
Student 2 First Name
Student 2 Last Name
Student 3 First Name
Student 3 Last Name
I want my student(s) to receive the Pfizer COVID-19 vaccine as soon as possible *
I want my student(s) to receive the Pfizer COVID-19 vaccine at a later date *
If "no", please share your concerns or reason for vaccine hesitancy. Answers will be kept confidential, but will help us in sharing concerns with county and state health departments.
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