H1N1 Influenza Vaccine Pre-Registration: Please complete this form to pre-register your 6 month to 4 year old child(ren) to receive H1N1 Flu Vaccine at a Town-sponsored clinic. You must be a resident of Somers to participate.
This form is for registration of pre-school aged children only. If your child is enrolled in the Somers Public School system, you will receive a form from the schools to register.
You will be contacted as vaccine becomes available and public clinics are scheduled. Pre-registrations for this age group will be honored in the order that registrations are received.
* Information is required.
Contact Information
Check here to have email confirmation of this request sent.
* Information is required.
Notes:
Thank you for your responses. You will be contacted when doses of vaccine are received and a public clinic is scheduled.
Because we have required you to include your e-mail address on your response, you'll receive a Tracking Number allowing you to view your response.
Internal Use Only, Leave Blank:
Please leave this field blank and remove any values that have been populated for it.
