Buckley Student / Staff Vaccination Sign up

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Completing this form indicates your interest in receiving the Pfizer Vaccine for COVID19 at the school on April 22nd, with second dose being schedule on May 13th on site. You are asked to receive BOTH doses at the same location.

Email *

Name of student / Staff member *

Birth date of student / staff member. Student MUST be 16 or older by April 22, 2021. *

I understand I will be receiving paperwork to complete prior to my student being vaccinated as minor students require parental consent for vaccination . *

Yes

My child prefers an appointment *

In the morning

In the afternoon

no preference

Send me a copy of my responses.

Submit

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