COVID-19 Vaccination Interest Form for Families

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COVID-19 Vaccination Interest Form for Families

This form is NOT a sign-up sheet for an appointment or vaccine. This is only a form of interest to provide our local health department with an estimation of families interested in the COVID-19 vaccine for their children aged 5-11.

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* Indicates required question

When a vaccine become available for children in the age range of 5-11 years old, would you want your child(ren) vaccinated? *

Yes

No

Other:

How many children in the age range of 5-11 would you require a vaccine for? *

0, I don't want a vaccine for my child(ren).

1

2

3

4

5

6

7

Other:

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This form was created inside of Mount Airy City Schools. Report Abuse