Back to School Bash Immunization Pre-Registration

Please complete this application form to pre-register for FREE immunizations on August 9, 2013 at the Back to School Bash to held at the Amway Center.


All patients must be accompanies by a parent or legal gardian. Legal guardians must supply proof of guardianship.

Please include at least one phone number where we can reach you during business hours and an email address that you check frequently. Your information is confidential.

Parent/Guardian General Information
   
Best Time to Call
   
   

  (day/month/year)    
Gender
   

Do you have a pediatrician?


Patient Eligibility

Legal Resident of United States

Currently living in Orange County, FL


Income Chart







8 - Family Size 8, Income Annual $74,016 Monthly $6,168.33

Employment Status



Unisured and not eligible for government assisted healthcare programs (such as Medicaid amd Medicare)


Appointments

Your immunization appointment will be confirmed via email.