COVID-19 Vaccine Clinic Registration

COVID Vaccine Clinic Registration

Please complete this form if you are interested in receiving your COVID-19 vaccine at Deerfield's COVID vaccine clinic on May 6, 2021. You must be 18 at the time of the vaccine clinic. Those who have already received 1 dose of either the Pfizer or Moderna vaccine are not eligible for this vaccine clinic.

Name*
First Last
Email*
Are you an employee or a student?*
- Student
- Employee
Will you be 18 years or older on May 6, 2021?*
- Yes
- No
When will you turn 18?
MM slash DD slash YYYY

If you are a student turning 18 before the end of the school year, you may be eligible to get the vaccine before departure from campus. This is not guaranteed.
Have you ever received a COVID vaccine?*
- Yes
- No
Because you have already received a COVID vaccine, you are not eligible for the vaccine clinic. If you are looking to schedule your 2nd shot appointment and need assistance with transportation, please email vaccine@deerfield.edu

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COVID-19 Vaccine Clinic Registration

COVID Vaccine Clinic Registration

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