5-11 Year Old COVID Vaccination Signup Form

5-11 Year Old COVID Vaccination Signup Form
The FDA and CDC have approved Pfizer Covid vaccinations for 5 to 11 year olds. The Little Rock School District is partnering with the Arkansas Department of Health to host three vaccine clinics. Parent must be present for vaccination. Locations will be at:

Chicot Elementary - November 15th from 3:30pm to 6:00pm.
11100 Chicot Rd. Mabelvale, AR 72103
Chicot Consent Form: English / Espanol

Henderson/Ignite Academy - November 16th from 3:30 to 6:00pm.
401 John Barrow Rd. Little Rock, AR 72205
Henderson Consent Form: English / Espanol

Washington Elementary - November 18th from 3:30 to 6:00pm
2700 S. Main St. Little Rock, AR 72206
Washington Consent Form: English / Espanol

Please bring signed and filled out consent forms linked above to the clinic.

Please sign up for your location and time below:
Student Name*

First NameLast Name
Parent Name*

First NameLast Name
Parent Email
example@example.com
Parent Phone*
Please enter a valid phone number.
Please select a Clinic Location and Time*
Should be Empty: