2018/19 SKIIP Sign-up Question Title * 1. Your name (First & Last): OK Question Title * 2. Your title: OK Question Title * 3. Your email address: OK Question Title * 4. Your phone number (Cell phone is okay): OK Question Title * 5. Your school district: Albuquerque Public Schools Animas Public Schools Artesia Public Schools Aztec Municipal Schools Belen Consolidated Schools Bernalillo Public Schools Bloomfield Schools Capitan Municipal Schools Carlsbad Municipal Schools Carrizozo Municipal Schools Central Consolidated Schools Chama Valley Schools Cimarron Public Schools Clayton Municipal Schools Cloudcroft Municipal Schools Clovis Municipal Schools Cobre Consolidated Schools Corona Public Schools Cuba Independent Schools Deming Public Schools Des Moines Municipal Schools Dexter Consolidated Schools Dora Consolidated Schools Dulce Independent Schools East Mountain Public Schools Elida Municipal Schools Espanola Public Schools Estancia Municipal Schools Eunice Public Schools Farmington Municipal Schools Floyd Municipal Schools Fort Sumner Municipal Schools Gadsden Independent Schools Gallup-McKinley County Schools Grady Municipal Schools Grants-Cibola County Schools Hagerman Municipal Schools Hatch Valley Public Schools Hobbs Municipal Schools Hondo Valley Public Schools House Municipal Schools Jal Public Schools Jemez Mountain Public Schools Jemez Valley Public Schools Lake Arthur Municipal Schools Las Cruces Public Schools Las Vegas City Public Schools Logan Municipal Schools Lordsburg Municipal Schools Los Alamos Public Schools Los Lunas Public Schools Loving Municipal Schools Lovington Public Schools Magdalena Municipal Schools Maxwell Municipal Schools Melrose Public Schools Mesa Vista Consolidated Schools Mora Independent Schools Moriarty Municipal Schools Mosquero Municipal Schools Mountainair Public Schools Pecos Independent Schools Peñasco Independent Schools Pojoaque Valley Public Schools Portales Municipal Schools Quemado Independent Schools Questa Independent Schools Raton Public Schools Reserve Independent Schools Rio Rancho Public Schools Roswell Independent Schools Roy Municipal Schools Ruidoso Municipal Schools San Jon Municipal Schools Santa Fe Public Schools Santa Rosa Consolidated Schools Silver Consolidated Schools Socorro Consolidated Schools Springer Municipal Schools Taos Municipal Schools Tatum Municipal Schools Texico Municipal Schools Truth or Consequences Municipal Schools Tucumcari Public Schools Tularosa Municipal Schools Vaughn Municipal Schools Wagon Mound Public Schools West Las Vegas Public Schools Zuni Public Schools OTHER OK Question Title * 6. For the 2018 - 2019 flu season, how many doses of flu vaccine do you anticipate needing for the schools you are signing up? Typically, we recommend ordering the same number as last year, or if you are a new school, 15-20% of your student population. If you're not sure how many doses you'll need, leave this section blank and follow-up with your SHA or NMIC to confirm the number of doses: OK Question Title * 7. Have you had an opportunity to discuss your clinic with your principal or superintendent? Yes, my principal/superintendent is supportive and has agreed that our school can host a SKIIP clinic No, but I expect my principal/superintendent's support OK Question Title * 8. Does your school or district have robo-call capabilities (recorded calls that can be sent to all of the parents/guardians of the students at the school)? Yes No Unsure OK Question Title * 9. If available in your area, would you like help from health sciences students or other clinical volunteers at your SKIIP clinic? Yes No Unsure OK Question Title * 10. School Information School Name Type of school (i.e. Public, Public-charter, Private, BIE/Tribal) Grades of school (i.e. Elementary, Middle, K-8) School street address School city School zip code School VFC PIN (if applicable) Number of students in school Does this school have a pre-school located on site? (Yes/No) OK Question Title * 11. Do you need to sign-up additional schools? Yes No OK NEXT