Childhood Vaccination Clinic Appointments
These clinics are for children 0-18 who are uninsured, underinsured, eligible for Badgercare/Medicaid, or Native American/Alaska Native.
If you have multiple children receiving vaccine, a new form will need to be completed for each child.
Name of Person Receiving Vaccine
Person Receiving Vaccine's Date of Birth
Please enter a valid phone number.
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)
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)
HPV (human papilloma virus)
MMR (measles, mumps, rubella)
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.
Should be Empty: