***Please complete one submission per student***

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* 2. What Time of Day Would You Like The Appointment to Be?

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* 3. Student Information

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* 4. (Parent/Guardian Contact Information) ***Please re enter your contact information if you are a student who is emancipated or 18+ completing this survey independently. 

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* 5. Which Vaccines Does Your Student Currently Need?

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* 6. If you selected the COVID-19 vaccination, which dose is your student need of? (If you DID NOT select the COVID-19 vaccine in question 5 please skip this question)

Thank you for expressing your interest in visiting one of the District of Columbia’s School Based Health Centers. Once this form is completed, please allow for up to 72 business hours for response. When contacted, the selected School Based Health Center Staff will provide to you the next available appointment time/date. Please be sure to click on done to ensure your answers have been saved and properly submitted.

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