October 2nd, Washington Island - CHILD Seasonal Flu/COVID Vaccination Appointment Form

October 2nd, Washington Island - CHILD Seasonal Flu/COVID Vaccination Appointment Form

If you need assistance with scheduling or have questions on eligibility, please call 920-746-2234 or email publichealth@co.door.wi.us.
Children enrolled in the Washington Island School do not need to make an appointment, they are scheduled through the school for flu vaccine.
Vaccine(s) Requested*

Flu (Influenza) Standard Dose (available for ages 6 months - 18 years)COVID-19 2025-26 (available for ages 12-18 years)Other Childhood Vaccines - Select to see options
Vaccine Payment/Eligibility - Flu*

Medicaid/BadgerCare+No Health InsuranceNative American or Alaskan NativeCommercial Insurance (Common Ground or United Healthcare Only)Dependent of a County of Door Employee AND on the County’s insurance planFree Influenza (Flu) Vaccine for Home Schooled Children (ages 4-18)Cash or Check $50
Dependent of a County of Door Employee are eligible for injectable flu vaccine only; nasal mist not available.
Influenza (Flu) Vaccine Choice

Injectable (available for ages 6 months-18 years)Nasal Mist (available for ages 2 years-18 years)
Vaccine Payment/Eligibility - COVID-19*

Commercial Insurance (Common Ground or United Healthcare Only)Dependent of a County of Door Employee AND on the County’s insurance planCash or Check $165
At this time, we do not have free COVID-19 vaccine available for children who have Medicaid/BadgerCare+, are uninsured, or are Native American/Alaskan Native.
Vaccine Eligibility - Other Childhood Vaccines*

Medicaid/BadgerCare+No Health InsuranceNative American or Alaskan Native
Other Child Vaccine(s) Requested

DTaP (Diphtheria, Tetanus, Pertussis)Hepatitis AHepatitis BHib (Haemophilus Influenzae Type B)HPV (Human Papillomavirus)Meningococcal ACWY (MenACWY)Meningococcal B (MenB)MMR (Measels, Mumps, Rubella)PneumococcalPolioRotavirusTdap (Tetanus, Diphtheria, Pertussis)VaricellaPlease determine other vaccines needed/available
Please select an appointment time.*
Contact Information

An appointment is required for each person requesting immunizations.
Child Receiving Vaccine(s)*

First NameLast Name
Parent/Guardian of Child

First NameLast Name
Parent or legal gaurdian must be present for appointment or provide signed authorization form.
Child's Date of Birth*

MonthDayYear
Child's Age
Phone Number*
Area code required
Email (by providing your email, you consent to receive confirmation and reminders via email)
example@example.com
Additional Notes:
Should be Empty:

October 2nd, Washington Island - CHILD Seasonal Flu/COVID Vaccination Appointment Form

Contact Information