COVID-19 Vaccination School Clinic Sign Up Sheet

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We are so glad you have made the choice to safeguard yourself, your friends, and/or family members against COVID-19. The COVID-19 vaccine prevents vaccinated people from getting and spreading the COVID virus. This is especially helpful to children who are susceptible to severe COVID-19, such as people with weaker immune systems or underlying medical conditions like asthma, Down’s Syndrome, congenital heart disease, obesity, diabetes, chronic lung disease, or sickle cell disease.

The vaccine can also prevent serious COVID-19 symptoms (leading to hospitalization or death) if a vaccinated person does become infected.

The COVID-19 vaccination also allows eligible students to follow a unique set of rules while in school (no quarantining, no pool testing, full sports participation, and more). If you are interested in receiving the COVID-19 vaccine at Hazelwood Elemetary Middle School, please complete the form below:

Family Name *

Number of Family Members: This number can include friends, and/or neighbors that will be joining your family to get vaccinated *

Transportation Needed *

Yes

Point of Contact Email

Point of Contact Phone Number *

Point of Contact Home Address: This is the address we will pick you and your family members up at if you need transportation. *

Emergency Contact *

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