Pediatric COVID-19 Vaccination Information
Thank you for your interest in the COVID-19 vaccination.
For patients who are between the ages of 5 – 12, please complete the form below to register to receive the vaccine for COVID-19.
Documentation required for minors (ages 5-12) 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.