Trimble Co. JR/SR High Covid/Flu Request Form

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Please fill out the form if you would like for your child to receive a covid vaccine and/or a flu vaccine. If you are requesting a vaccine for more than one child, please fill out a separate form for each child that will be vaccinated. Vaccinations will take place on March 11, 2022 at TC Jr/Sr High 9:30am-11:30am. A parent/guardian must be on site with the child in order for them to be vaccinated. Please call 502-663-0073 if you have any questions.

Student's First and Last Name *

Student's Age *

Which vaccine are you requesting for your child? *

Covid Vaccine

Flu Vaccine

Covid and Flu Vaccine

Covid Booster

Required

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