Pfizer Vaccine Pre-Registration Form
The Brockton Public Schools, the Mayor's Office, and the Brockton Board of Health are planning a vaccine clinic for BPS students ages 16 and older. Their involvement is completely voluntary and optional. If you'd like your child to receive the vaccine, we ask that you complete this pre-registration form as soon as possible. Students will receive a consent form from their dean's office (at BHS) or their main office (at the Keith Center, Edison Academy and Huntington) early next week.
Student's ID Number
Brockton High School
Champion High School
Frederick Douglass Academy
Huntington Therapeutic Day School
Parent/Guardian's Phone Number
Please enter a valid phone number.
Parent/Guardian's Email Address
Student's Date of Birth
I understand that my child must be 16 or over at the time of the vaccine clinic to qualify.
Do you and/or another parent, guardian, adult family member or caregiver intend to join the student to get vaccinated?
How many adults will be joining the student to be vaccinated?
Adult 1's Name
Adult 1's Relation to Child
Adult 2's Name
Adult 2's Relation to Child
Adult 3's Name
Adult 3's Relation to Child
Adult 4's Name
Adult 4's Relation to Child
Should be Empty: