Stockbridge-Munsee Community

Pediatric COVID Vaccination Registration Request Form

The Stockbridge-Munsee Community is offering the Pfizer Pediatric Vaccine to help children stay safe from COVID-19 at a Vaccine Event at the Mohican Family Center (MFC), N8605 Oak St., Bowler, WI 54416 on Saturday, November 13th (1st shot) and Tuesday, December 4th (2nd shot). In addition to the Vaccine Events at the MFC, the Stockbridge-Munsee Health and Wellness Center will offer the Pfizer Pediatric Vaccine during normal hours (M-F 8:00am – 4:30pm).

For more information about the recently FDA and CDC approved Pfizer Pediatric Covid-19 Vaccine for children ages 5-11. CDC Recommends Pediatric COVID-19 Vaccine for Children 5 to 11 Years

Please complete a survey for each individual ages 5-11 years who would like to be scheduled for a COVID Vaccine.

Question Title

* 1. Name of person to receive the vaccine

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. What is the date of birth for the person to be vaccinated? (mm/dd/yyyy)

Question Title

* 3. The name of the parent or legal guardian that will be bringing the child?

Question Title

* 4. Please select where you would like to receive the vaccinations:

Pediatric Vaccination Event at the Mohican Family Center (November 13th and December 4th)

Appointment at the Stockbridge-Munsee Health and Wellness Center during normal office hours. (Mon-Fri, 8 am- 4:30 pm)

Question Title

* 5. What size T-Shirt does you child wear?

Youth X-Small (4-5)

Youth Small (6-7)

Youth Medium (8-10)

Youth Large (12-14)

Youth X-Large (16-18)

You have now completed Step 1 of the COVID-19 Vaccine Registration. Please be patient. A Scheduler will contact you to schedule. Thank you.