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St. Bernards COVID Vaccine Clinic Interest Form
If you intend to have your student (12 years +) vaccinated at our clinic on August 18th, please fill out this form to ensure we have the correct number of doses available. Note that you must complete the consent form found on our website in Parent Resources for your student to receive the vaccine.
Parent/Guardian Name
*
First Name
Last Name
Student Name
*
First Name
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Campus
*
Please Select
Nettleton Junior High School
Nettleton High School
Nettleton Virtual Academy
Submit
Should be Empty: