COVID-19 Vaccine Registration Form
This is a registration form for the CW Henry Vaccine Event on Monday, February 28, 2022. Some notes: 1. The Entrance is on Carpenter, to the left of main entrance. 2. Parents/caregivers should come to Henry and accompany child, but can appoint a trusted staff member should they be absolutely unavailable. 3. If you are previously vaccinated and coming for a 2nd shot or a booster, you must bring vaccine card. ***WALK INs WELCOME! MOST TIMES HAVE OPEN SLOTS!***
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex as Identified on Insurance
Female
Male
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Back
Next
Are you a current faculty or staff member or student at CW Henry or a parent of a student at CW Henry?
*
Yes
No
What classroom are you in?
What is your teacher's name?
Which shot are you scheduling?
*
First shot (child under 12)
Second shot (child under 12)
First shot (adult (over 12)
Second shot (adult over 12)
Booster (adult 16 and up)
CW Henry Student/Staff/Parent Appointment
Community Appointment
Register
Should be Empty: