Vaccine Interest List

"*" indicates required fields

We are working with a pharmacy to schedule a vaccine clinic for our students ages 12+. Please indicate your interest below. This is not a request for an appointment. Once we have details confirmed, we will send a follow-up with appointment details. Thank you.

Student Name*

First Last

Date of Birth*

Grade*

We may have a small number of vaccine appointments for Berman parents as well. Please indicate interest below.

Parent Vaccine Interest

Yes - I would like a parent appointment

Comments

This field is for validation purposes and should be left unchanged.