Ages 16 and older Department of Public Health COVID Vaccination Sign-up at LCHS May 4th 3-6PM

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Our local health department will be offering the COVID Vaccination for students ages 16 and older at LCHS. They will also be able to administer vaccinations for parents/caregivers. If you are wanting for your child or yourself to receive the COVID-19 vaccination, please complete this form by Friday, April 30th (12 noon). The Pfizer vaccination will be administered at Lumpkin County High School on May 4th from 3 pm-6 pm. The Parent/Guardian will need to be present with any student receiving the vaccination. By completing this form, you will be securing an appointment time. You will not receive verification of this appointment, so please note down the appointment time that you selected.

You will need to bring a photo copy (front and back) of your insurance card.

Email *

Name of person requesting to receive the COVID-19 Vaccination (Last, First) *

Please select if this appointment for a student or parent/guardian. *

Student

Parent/Guardian

Date of Birth of patient *

YYYY

Please select an appointment time: *

This appointment is taken. Please select another appointment time.

3:10

3:15

3:20

3:25

3:30

3:35

3:40

3:45

3:50

3:55

4:00

4:05

4:10

4:15

4:20

4:25

4:30

4:35

4:40

4:45

4:50

4:55

This appointment is taken. Please select another appointment time.

5:05

5:10

5:15

5:20

5:25

5:30

5:35

5:40

5:45

5:50

5:55

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Lumpkin County School System. Report Abuse

Forms