Childhood Vaccination Clinic Appointments
These clinics are for children 0-18 who are uninsured, underinsured, eligible for Badgercare/Medicaid, or Native American/Alaska Native.
Demographics
If you have multiple children receiving vaccine, a new form will need to be completed for each child.
Name of Person Receiving Vaccine
*
First Name
Last Name
Preferred Name/Pronouns
Person Receiving Vaccine's Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Eligibility/Vaccines Needed
State Supplied Vaccine Eligibility
*
Medicaid/Badger Care Enrolled or Eligible
Native American or Alaska Native
No Health Insurance
Insured, Vaccines Not Covered
Do you know which vaccines your child needs or which vaccines you would like your child to receive?
*
I do not know what vaccines my child needs- please determine at their appointment
I know which vaccines my child needs/I want them to receive (please select below)
Additional Comment:
Vaccine(s) Requested (Please note we do use combination vaccines when able, so your child may not receive this number of vaccines)
Tetanus, Diphtheria, Pertussis
Hib (Haemophilus influenzae type B)
Hepatitis A
Hepatitis B
HPV (human papilloma virus)
Influenza
MMR (measles, mumps, rubella)
Meningitis
Meningitis B
Pneumococcal
Polio
Rotavirus
Varicella
COVID-19
Appointments
Clinics alternate between locations each month. A new form will need to be filled out for each appointment.
West Side Boys and Girls Club- 311 S. Oneida St.
East Side Boys and Girls Club- 1451 University Ave.
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