First Name

Last Name

Date of Birth (MM/DD/YYYY)

Parent Name

Address

Email

Phone

Clinic Date—Please choose an option—Thursday, April 16, 2:30-5:00pmTuesday, May 19, 2:30-5:00pm

Preferred LanguageEnglishSpanish

Preferred Communication MethodPhoneTextEmail

Please select the reason your child is VFC EligibleChild has no health InsuranceChild is on MedicaidChild has health insurance that does not cover immunizationsChild is American Indian or Alaskan Native

Children with health insurance that covers immunizations or Hawk-I are not VFC Eligible – please go to your medical clinic for shots.

Please print our intake form if you are able, as it will save time during the registration process.