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COVID VACCINE SIGN UP FORM
The Wayne County Health Division would like to provide the opportunity for staff, students/families to be vaccinated. This form must be submitted by 2:00 pm Thursday, September 30, 2021. Please fill out one form per individual family member or staff member that anticipates receiving the COVID vaccine. The first vaccine will be administered on October 14, 2021 and the second dose will be administered on November 4, 2021.
Copy and Paste the following link for Registration Form of MINORS (must fill out by hand)
https://docs.google.com/document/d/1aMvFNqvzIVjocWF6-LK8GHmJ0aOMqi4-/edit?usp=sharing&ouid=112088527528368438217&rtpof=true&sd=true
Copy and Paste the following link for Pfizer Fact Sheet
https://drive.google.com/file/d/1NQyvyiR9_EOJdJ1XusuUxGmjsK-lRGA9/view?usp=sharing
* Indicates required question
Email
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Your email
Choose one of the following
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Student
Parent/Guardian
Option 3
Last Name
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Your answer
First Name
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Your answer
Date of birth of individual who is receiving the COVID vaccine.
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Your answer
Current age of individual to receive the COVID vaccine on this visit. (student must be 12 years old on the day of the vaccine)
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12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
Over 18 years old
Other:
School
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OW Best
AHS
Other
Please select a clinic location
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Annapolis High School, October 14, 2021, 9:00 a.m. - 11:00 a.m.
O. W. Best Middle School, October 14, 12:00 p.m. - 2:00 p.m.
I understand that all children in school regardless of age must have parental permission to receive the the COVID vaccine. Parents DO NOT need to be present in order for students to receive the vaccine. Please select "Yes" to confirm your understanding.
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Yes, I understand all students must have parental permission regardless of being of adult age.
I understand that children, and adults over the age of 18 must complete the registration COVID consent form and have read and acknowledge the Pfizer Information and Fact form.
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Yes, I understand that children and adults over the age of 18 must complete the Registration Form General and have read and acknowledge the Pfizer Information and Fact form.
I understand that transportation to and from the site is the responsibility of the parent/guardian. Please select the only response.
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Yes, I understand that transportation to and from the site is the responsibility of the parent/guardian.
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This form was created inside of Dearborn Heights School District #7.
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