Keiki (Ages 5-11) Pfizer Vaccination Consent Form
Kahului Elementary School (Drive-Thru) - Sunday, December 5th, 2021
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Keiki (Ages 5-11 ONLY) Vaccination Consent Form
Kahului Elementary School (Drive-Thru) - Sunday, December 5th, 2021
Keiki's Name
*
First Name
Last Name
Gender
*
Male
Female
Other
Date of Birth
*
/
Month
/
Day
Year
Date
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Date of Birth
*
/
Month
/
Day
Year
Date
Primary Contact number for Parent/Guardian
*
-
Area Code
Phone Number
Parent/Guardian Email
*
example@example.com
What category best describes your race (one or more may be marked)
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Please specify your ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Primary Insurance Information
Insurance Company Name (primary)
*
Subscriber ID
*
Upload ID and Insurance Card
*
Browse Files
Cancel
of
Acknowledgement
Parent/Guardian Signature
*
DateTime
*
Submit
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