North Penn Vaccine Clinic Registration

Clinic Date and Location:

Thursday, September 3, 2026
4:00 PM – 7:00 PM

Penndale Middle School – Auxiliary Gym Entrance
400 Penn Street
Lansdale, PA 19446

(Please use the Church Road parking lot for the Auxiliary Gym Entrance)

Age of Person To Receive Vaccine

How old is the patient who you are scheduling an appointment for? DO NOT USE DECIMALS.

Grade for the 2026-2027 School Year

Child's North Penn School

What are you looking for at this clinic?

Have you received a Vaccine Through Skippack Pharmacy Before?

School-Required Vaccines (K–12)

***while below is a general reference, please follow what the school has instructed you that is required***

DTaP or Tdap

DTaP (Daptacel, Infanrix, 6 weeks–6 years) – Routine five-dose series at 2, 4, 6, 15–18 months, and 4–6 years.
Tdap (Boostrix, Adacel, typically 10–18 years) – One routine dose at age 11–12 years. May also be used as part of catch-up vaccination for children ages 7–18 when appropriate.

Polio / IPV (IPOL, 6 weeks–18 years) – Routine four-dose series at 2, 4, 6–18 months, and 4–6 years. Catch-up dosing depends on previous vaccination history.

MMR (M-M-R II, Priorix, 12 months–18 years) – Routine two-dose series at 12–15 months and 4–6 years. For catch-up, doses are given at least 4 weeks apart.

Hepatitis B (Engerix-B, Recombivax HB, birth–18 years) – Routine three-dose series. For catch-up, typically given at 0, 1–2, and 6 months.

Varicella / Chickenpox (Varivax, 12 months–18 years) – Routine two-dose series at 12–15 months and 4–6 years. For catch-up, spacing between doses depends on the child’s age.

Additional School-Required Vaccines — 7th & 12th Grade
Tdap (Boostrix, Adacel) – One dose is required for entry into 7th grade in Pennsylvania.

Meningococcal ACWY (MenQuadfi) – One dose is required for entry into 7th grade, with an additional dose required for entry into 12th grade. Routine adolescent dosing is at ages 11–12 and 16 years.

Which Vaccine Are You Scheduling an Appointment For? **Please be sure to select the correct vaccines which match up to your child's age & please confirm the vaccines you need with your school prior to scheduling an appointment.**

School-Required Vaccine Confirmation: Before scheduling an appointment, please confirm with your child’s school or school nurse which vaccine(s) your child is required to receive. By selecting the option below, I attest that I have contacted my child’s school district, school nurse, or appropriate school staff and have confirmed which vaccine(s) my child needs to meet their school immunization requirements. If you are unsure which vaccine your child needs, please do not schedule an appointment until you have confirmed this information with the school. Your child’s school or school nurse is responsible for determining which vaccine(s) are required to satisfy the school’s immunization requirements.

When do you plan on attending? (9/3/26 at Penndale Middle School)

Patient Name

First NameLast Name

Patient Date of Birth

Date

Gender at Birth

Email of Patient (or caregiver filling this out) --- preferably non-comcast.net email addresses as Comcast has been filtering our emails or sending them to spam. If it is a comcast.net email address & you sign up, if you see the THANK YOU page after submitting, your appointment is confirmed, you do not need to call to see if it is confirmed.

example@example.com

Phone Number

Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Demographic Information (Optional)

Please answer "Yes" or "No" to the questions below concerning the patient's Medical History. The caregiver may fill this out on behalf of the patient. If unsure or you answer "Yes" to any of these and have concerns, please consult your doctor prior to receiving a vaccine. To save you time in person, we ask these questions now.

Rows	Yes	No
Allergic to gelatin, latex, yeast, neomycin or any vaccine ingredient
Serious reaction after getting a vaccine
Dizzy or faint before, during or after an immunization
Seizure or other brain or nervous system condition, including Guillain-Barré syndrome (GBS)
Taken medications that affect the immune system or had radiation treatment in the last 6 months
Weakened immune system because of active cancer, HIV/AIDS, transplant or other medical condition
Diagnosed with a heart condition or Multisystem Inflammatory Syndrome (MIS-A or MIS-C)

Coverage: I understand that I will be receiving a vaccine through Skippack Pharmacy. On any statement received from insurances, the pharmacy's legal name, "Yogikrupa Health, LLC," may appear. By registering, I authorize Skippack Pharmacy to bill my insurance for the cost of the vaccine and cost of administration or provide it through the VFC program if uninsured, under-insured or on Medicaid.

PRESCRIPTION RX CARD UPLOAD: Please click "Upload Image or File" and upload copies of those cards herein and then click "Next." For most insurances, our system can pull up your information but for some (including CAPITALRX), our system cannot pull it automatically. Please ensure the card has the letters "RX" on it. If you have difficulties uploading it here, please bring with you to your vaccine appointment.***IF you have uploaded this in the past or provided it at check-in to the Skippack Pharmacy team or volunteers & there are no changes, you DO NOT need to do this again.***

Please input the numbers/letters from your Prescription Insurance card. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. If your card does not have one of the below, please leave that field blank. If you do not have insurance, put in the last 4 of your SSN. After filling it out, hit "Next." Not providing this information now could delay your registration on-site.

What is your preferred site of administration for the vaccine(s)?

Do you have any comments, feedback, etc. to help us improve? LEAVE BLANK IF NONE & skip to last questions

CONSENT & WAIVER: By clicking the box below, I am indicating my consent and agree my electronic signature is the legal equivalent of my manual signature on this Agreement. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so. Please note that patients under 18 must have the consent of a parent or guardian.

Signature Of Parent (if under 18) or Patient

Date Signed

North Penn Back to School Vaccine Clinic