COVID-19 Vaccination Information

Thank you for your interest in the COVID-19 vaccination.

Please complete the form below to register to receive the vaccine for COVID-19.

Documentation required for minors (ages 12-17) receiving the Covid-19 vaccine:

  • Parents/Legal Guardians bringing minor must present a valid form of ID (driver’s license) at the time of vaccine
  • Notarized written consent in cases where the parent/guardian is not present at the time of vaccination
    • Parents may also call 502-SHOT to give verbal consent before vaccination if unable to provide written documentation
  • Notarized Affidavit (link below)
  • Letter of written consent by Children’s Division, or designee, for all minors under the care of Department of Social Services/Division of Youth Services
  • Documentation of proof if pregnant/married/emancipated minor
  • Documentation from person/entities, such as governmental or nonprofit agency, if the youth is homeless

Click the link below to access the Affidavit form. The form can be completed online, then printed.

Minor Consent Form

A third dose of the PfizerNBioTech vaccine may be administered to moderately to severely immunocompromised people due to a medical condition or combination of immunosuppressive medication or treatments including but not limited to the following:

  • Receiving active cancer treatment for tumors or cancers of the blood
  • Received an organ transplant and are taking medicine to suppress the immune system
  • Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
  • Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
  • Advanced or untreated HIV infection
  • Active treatment with high-dose corticosteroids or other drugs that may suppress immune response

Registration Form

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By providing my phone number and/or email address, I opt-in to receive SMS messages and/or Emails from Freeman Health System.

If you have any questions, please call 417-502-SHOT (7468).