Cville Schools Free Vaccine Permission Form (Step 1)
The Blue Ridge Health Department (BRHD) is hosting a vaccine clinic on Thursday, May 20 at CHS. CHS and Walker students age 12+ are eligible. Please complete this form for the CHS clinic. Register by 5pm, Wednesday, May 19.

 (We will later have a clinic at Buford and will use a SEPARATE form for those registrations.)

Any eligible Walker and CHS students who are learning virtually that day can still enroll and go to the MLK Performing Arts Center at CHS.

STEP 1: Complete this brief survey to help the schools plan
STEP 2: Register with the Virginia Department of Health's VASE System. (See last page of this form.)
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Student First Name *
Student Last Name *
Student Grade
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Best Number to Contact Parent/Guardian
I give permission for my child to walk or ride a bus to another Charlottesville City School to receive the vaccine.
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I give permission for Blue Ridge Health Department to share appointment information with Charlottesville City Schools (from Step 2 form) to help us coordinate this event.
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Questions or comments?
Remember, this form is STEP 1. Please click "submit" to move to STEP 2, registering with the VA Dept. of Health.
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