COVID-19 Vaccine Events

(Located in the back of the
Department of Social Service Building)

First Shot: July 30, 2022

Second Shot: August 27, 2022

9AM-2PM

"*" indicates required fields

Date(s) That You Plan To Attend:*

Fecha(s) En Las Que Planea Pasar:

July 30, 2022 | 9AM-2PM

August 27, 2022 | 9AM-2PM

I will attend both dates.

Child's Name (Patient)*

Nombre del Niño (Paciente)

First Last

Parent/Guardian's Name*

Nombre del Padre/Guardián

First Last

Address

Dirección física

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Phone Number

Número de teléfono

Email Address*

Dirección de correo electrónico

Enter Email Confirm Email

This field is for validation purposes and should be left unchanged.