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COVID-19 Pediatric Vaccine Request

COVID-19 Pediatric Vaccination Request

Step 1 of 3 - Personal Information

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Please do not submit duplicate registration requests as this may delay processing of your request.
Parent/Guardian Information
Guardian Name*
Legal First Name Legal Last Name
Hidden
User Age
Please enter a number from 1 to 999.
Parent/Guardian Contact Information
Zip Code*
Phone*
Is this a mobile number?*
- Yes
- No
Email*
Enter Email Confirm Email

If you do not have an email address please enter: noemail@noemail.com
Are you a University of Kentucky HMO/PPO/EPO/RHP/SAVER member:*
- Yes
- No
Occupation Information
Are you an employee of the University of Kentucky/UK HealthCare?*
- Yes
- No
I am a...*
- UK HealthCare Employee
- University of Kentucky Employee
- University of Kentucky Student
UK ID*

About Your Child
How many children will be vaccinated?*
You may request and submit information on up to five children. If you are responsible for more than five (5) children, please provide information on five here and the other children will be allowed to be vaccinated at the same time with their information being collected at the time of vaccination.
Child 1
Full Legal Name*
First Last
Date of Birth*
Gender*
Will this be their first, second, or third dose?*
Which manufacturer would you like them to receive?*
Date of their first vaccine dose*
Which manufacturer did they receive?*
Date of their second vaccine dose*
Date of their third vaccine dose*
Child 2
Full Legal Name*
First Last
Date of Birth*
Gender*
Will this be their first, second, or third dose?*
Which manufacturer would you like them to receive?*
Date of their first vaccine dose*
Which manufacturer did they receive?*
Date of their second vaccine dose*
Date of their third vaccine dose*
Child 3
Full Legal Name*
First Last
Date of Birth*
Gender*
Will this be their first, second, or third dose?*
Which manufacturer would you like them to receive?*
Date of their first vaccine dose*
Which manufacturer did they receive?*
Date of their second vaccine dose*
Date of their third vaccine dose*
Child 4
Full Legal Name*
First Last
Date of Birth*
Gender*
Will this be their first, second, or third dose?*
Which manufacturer would you like them to receive?*
Date of their first vaccine dose*
Which manufacturer did they receive?*
Date of their second vaccine dose*
Date of their third vaccine dose*
Child 5
Full Legal Name*
First Last
Date of Birth*
Gender*
Will this be their first, second, or third dose?*
Which manufacturer would you like them to receive?*
Date of their first vaccine dose*
Which manufacturer did they receive?*
Date of their second vaccine dose*
Date of their third vaccine dose*
Hidden
Past 90 Days
Please note that no child may receive a vaccination shot if they have received either Convalescent Plasma or Monoclonal Antibody therapy for COVID-19 in the past 90 days. Have any of the children listed above received either Convalescent Plasma or Monoclonal Antibody therapy for COVID-19 in the last 90 days?*
- Yes
- No
Date administered*

Comments
This field is for validation purposes and should be left unchanged.

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