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Student and Family Vaccination at Queens Medical Centre
Please only complete this form if you or a family member would like to book in for a vaccination for this Sunday 12 September between 9 am and 12 pm.
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Name of student
*
Your answer
Do you wish to have a vaccine at Queens Road Medical Centre as part of an Edgewater College vaccine arrangement? This will occur on Sunday 12 September between 9 am and 5 pm.
Yes, just for me
Yes, along with other family members
Not for me, but yes for the family members listed below
Other:
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Please give the full names of all family / extended family members who would like to receive a Covid-19 vaccination. Please note any children aged 12-15 must be accompanied by their parent or guardian who can give permission for them to receive the vaccine.
Your answer
Please give the total number of people for vaccination
Your answer
Please give a preferred timeframe
Any time between 9 am and 5 pm is fine
9 am - 11 am
11 am - 1 pm
1 pm - 3 pm
3 pm - 5 pm
Other:
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Email address for further contact - information about your allocated time and what to do on the day will be emailed to this address:
*
Your answer
Any other questions / information?
Your answer
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