COVID-19 Vaccine Appointment Form
Grants Pass High School
Appointment
*
Name
*
First Name
Last Name
Address
*
Mailing Address
Mailing Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Cell Phone Preferred)
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: