Covid 19 Vaccination Sign up (McNabb Middle School) – Montgomery County

Your vaccine will be given at the MCNABB MIDDLE SCHOOL

3570 Indian Mound Dr, Mt Sterling, KY 40353

MONDAY, February 28, 2022

4:00 – 6:00

Shots given in the cafeteria.

ALL VACCINES WILL BE AVAILABLE FOR CHILDREN AGES 5 & UP AND THE GENERAL PUBLIC

BRING YOUR VACCINATION CARD AND INSURANCE CARD

THERE IS NO CHARGE TO YOU FOR THE VACCINATION

PFIZER AND MODERNA BOOSTER GIVEN 5 MONTHS AFTER 2^ND SHOT

JOHNSON AND JOHNSON BOOSTER GIVEN AFTER 2 MONTHS FROM SHOT

If you wish to cancel your appointment email ConnieA.Copher@ky.gov

Step 1 of 2

Confirmation Number
COVID-19 BOOSTER & 3RD DOSE VACCINATION SIGN-UP (MONTGOMERY COUNTY HEALTH)

***PLEASE READ AND DO THE FOLLOWING***
Note: Parking is in the small side lot behind the cafeteria. Come in through the back cafeteria doors. Doors will open at 4pm.
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County in which you reside or work*
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County in which you reside or work old*
Name*
First Last
Date of Birth*
Address*
Street Address City State ZIP Code
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Date of Birth (For 40+)*
MM slash DD slash YYYY
Phone Number*
Email

Type of Vaccine*
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I certify that this is my First Dose Vaccine.*
- Yes
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You certify that you understand that in order to receive the Booster shot, you must present your Covid Vaccine card showing your first two shots*
- Yes
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Consent*
3rd Dose: I attest that I am immunocompromised and am eligible for a third dose of vaccine based on the criteria below*
• Receiving active cancer treatment for tumors or cancers of the blood;

• Received an organ transplant and am taking medicine to suppress my immune system;

• Received a stem cell transplant within the last 2 years or am taking medicine to suppress the immune system;

• Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, WiskottAldrich syndrome);

• Advanced or untreated HIV infection;

• Active treatment with high-dose corticosteroids or other drugs that suppress my immune response.
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Consent*
Booster Dose: I attest that I meet one of the following criteria as defined by the CDC and ACIP*
• 65 years or older

• 18 years or older who live in long-term care settings

• 18 years and older who have underlying medical conditions

• 18 years and older who work or live in high-risk settings (such as healthcare workers, first responders, and those working/living in residential facilities)
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I certify that this is my first and ONLY dose for the Johnson & Johnson Vaccine.*
- Yes
Consent*
Yes I have read this (HIPPA) EN or (HIPPA) ES
Consent*
Yes I have read this (FDA) EN or (FDA) ES*
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I understand that I am signing up for the FIRST DOSE of Covid vaccine*
YOU WILL BE TURNED AWAY IF YOU SIGN UP FOR THE WRONG DOSE.
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Date*
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When was your first dose?*
Schedule Date*
CAPTCHA

Your vaccine will be given at the MCNABB MIDDLE SCHOOL

3570 Indian Mound Dr, Mt Sterling, KY 40353

MONDAY, February 28, 2022

4:00 – 6:00

Shots given in the cafeteria.

ALL VACCINES WILL BE AVAILABLE FOR CHILDREN AGES 5 & UP AND THE GENERAL PUBLIC

BRING YOUR VACCINATION CARD AND INSURANCE CARD

THERE IS NO CHARGE TO YOU FOR THE VACCINATION

PFIZER AND MODERNA BOOSTER GIVEN 5 MONTHS AFTER 2ND SHOT

JOHNSON AND JOHNSON BOOSTER GIVEN AFTER 2 MONTHS FROM SHOT

Step 1 of 2

COVID-19 BOOSTER & 3RD DOSE VACCINATION SIGN-UP (MONTGOMERY COUNTY HEALTH)

***PLEASE READ AND DO THE FOLLOWING***

Note: Parking is in the small side lot behind the cafeteria. Come in through the back cafeteria doors. Doors will open at 4pm.

PFIZER AND MODERNA BOOSTER GIVEN 5 MONTHS AFTER 2^ND SHOT

PLEASE READ AND DO THE FOLLOWING