MPTCS Covid Vaccine Interest Form

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

Plans are underway to bring a vaccine clinic to MPTC High School. To determine the number of medical staff needed to implement the vaccine, we need to know how many students (ages 12-17), parents and staff are interested in receiving the vaccine. PLEASE COMPLETE THIS FORM NO LATER THAN THURSDAY, August 26th at 4:00 PM.

Parent/Staff Name: *

Parent/Staff Email: *

Parent/Staff Phone number: *

Address *

Please list all family members who will receive vaccine (list adults and minors [the vaccine is available for minors ages 12-17 and adults]) *

Please list birthdates of all family members who will receive the vaccine *

PLEASE READ

Parents must accompany all minors (ages 12-17) who will receive the vaccine. You will be required to bring your insurance information. However, having insurance is not a requirement to receive the vaccine. Thank you for completing this interest form.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Marion P Thomas Charter School. Report Abuse

Forms