www.chathamhealth.org 2014 Flu Clinic Registration and Consent Form Please complete the information requested here so that we can contact you in case of clinic changes. Each individual receiving a vaccine will need to complete a separate consent form provided at the end of this registration. Question Title * 1. Please enter your email address so that we can contact you in case of clinic changes. Question Title * 2. Should we use this email address to notify you of next year's flu clinic? Yes No Question Title * 3. Please indicate the number of people and their ages to be vaccinated. 0-18 years old 1 2 3 4 5 0-18 years old menu 19 years and older 1 2 3 4 5 19 years and older menu Question Title * 4. Which clinic do you plan to attend ? Colchester Town Hall- September 15, 2014, 3-6pm East Hampton High School - September 17, 2014, 3-6pm Portland High School - September 25, 2014, 3-6pm Marlborough, Elmer Thienes School - September 22, 2014, 3-6pm East Haddam High School- September 24, 2014, 3-6pm Hebron, Gilead School- September 29, 2014, 3-6pm Haddam, Regional School District 17 Central Office - September 30, 2014, 3-7pm Question Title * 5. Have you attended any Chatham Health District flu clinics in the past? Yes No Question Title * 6. Do you have any feedback for us that will help us improve our clinics? Question Title * 7. How did you hear about this clinic? Notification from my child's school Saw it in the newspaper Heard about it from my child's daycare Other (please specify) Next