Covid 19 Pfizer-BioTech Vaccine
for 5 through 11 years of age

Name _________________________________________________________________

Date of Birth  ___________________________________________________________

Gender    Female    Male    Other

Address  _______________________________________________________________

Phone   _____________________     Phone  __________________________

Email  _____________________________    Email  _____________________________

Nationality     U.S.     Mexico      Canada     

Ethnicity     Hispanic/Latino        Not Hispanic/Latino

Race    American Indian or Alaskan Native
            Asian
            Black or African-American
            Hispanic or Latino
            Middle Eastern or North African
            Native Hawaiian or Other Pacific Islander
            Other
            Unknown
            White

Birth Country  ____________________________________________________________

Birth State  ______________________________________________________________

________________________________________________________________________________________
For office use only

Dose #1:                                                                               Dose #2:                                                                         

Date  _______________________________                      Date:  _______________________________

Lot #  _______________________________                      Lot #  _______________________________

Exp Date: ____________________________                     Exp Date:  ___________________________

Arm Admin: ___________________________                    Arm Admin:  ___________________________

Covid Card Given:  ________________                              Covid Card Updated:  ___________________