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* 1. If my child's/children's school would host a vaccination clinic, I would be interested in my child(ren) receiving a vaccination.  (Must be 16 years of age or older.)

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* 2. Name(s) of above student(s), age 16 or older, who may be interested in getting the COVID vaccination.

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* 3. Name(s) of Parent(s) or Guardians of student(s) who will be getting vaccinated?

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* 4. The name of the school in which the student(s) is attending?

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* 5. Parent Phone Number

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* 6. Parent email address.  (We will email more information to this address.  If no email is provided, we will call the number provided to provide other options.)

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