COVID-19 Vaccine Clinic Registration

COVID-19 Vaccine Clinic Registration
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Student must be 12+ to receive the first dose
School/Program*
Which school's clinic would you like to attend?*
Clinic
First Dose

MonthDayYear
First Dose String
Second Dose

MonthDayYear
Second Dose String
9:00 - 10:00 a.m.10:30 - 11:30 a.m.12:00 - 1:00 p.m.
The vaccination clinic at {clinic} will be:
- First Dose: {firstDose18} between {time}
- Second Dose: {secondDose19} between {time}
Shoreline Fire Department requests that you arrive at the beginning of the scheduled time.
Yes
We are no longer able to accept registrations for the {schoolprogram} clinic. Registration closed at noon the day before the first dose so that Shoreline Fire Department had time to prepare.
Sept 20

MonthDayYear
Sept 23

MonthDayYear
Sept 28

MonthDayYear
Sept 30

MonthDayYear
Oct 11

MonthDayYear
Oct 14

MonthDayYear
Oct 19

MonthDayYear
Oct 21

MonthDayYear
Current Date

MonthDayYear
Date
Close Date

MonthDayYear
Date
Current Time

Hour Minutes
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Email*
Phone Number*
Format: (000) 000-0000.
Should be Empty:

Parent/Guardian Information