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* 1. Name

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* 2. Contact Information 

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* 3. The Pfizer COVID-19 vaccine has EUA approval for ages 16-up. It is a 2-dose series, required 21 days apart. Are you interested in getting the Pfizer COVID-19 vaccine (both doses) for your child/student?

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* 4. Are you interested in receiving the Pfizer COVID-19 vaccine (both doses) for yourself?

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* 5. If you answered yes to the previous question, would an evening clinic (5p-7p) at your child’s school be beneficial to administer the vaccine to you and/or your child?

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* 6. If no to the previous question, are there other venues or times that would be best for providing the vaccine to you and/or your child?

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* 7. Are there any questions regarding the COVID vaccine that you would like to discuss with a medical professional?  If so, may we contact you?

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