Grand Meadow Public School COVID Vaccine Interest

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* 1. If you have a child(ren) aged 16, 17 or 18 are you interested in having your child(ren) vaccinated with the Pfizer Vaccine?

Yes

No

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* 2. If so, which option would work best?

On site at Grand Meadow Public School during school hours

On a weekend

On a week night

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* 3. If interested please leave the following for contact purposes
First Name
Last Name
Date of Birth
Grade

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* 4. Do you have additional family members you would like to have receive the vaccine that is 16 yrs of age or older?

Yes

No