Back to School Bash
Immunization Pre-Registration

Please complete this application form to pre-register for FREE immunizations on August 13, 2011 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

Date:
Parent First Name:		Parent Middle Name:
Parent Last Name:		Phone:
Email:		Cell:
Address:		Apt (optional):
City:		Best Time to Call

State:
Zip:

Childs First Name		Childs Middle Name
Childs Last Name
Date Of Birth:
	(day/month/year)
Gender
Age:
Do you have a pediatrician? Yes No
Please provide your Pediatricians Name.

Patient Eligibility

Legal Resident of United States
Yes
No

Currently living in Orange County, FL
Yes
No

Income Chart
1 - Family Size 1, Income Annual $21,660, Monthly $1,805
2 - Family Size 2, Income Annual $29.136, Monthly $2,428.33
3 - Family Size 3, Income Annual $36,624, Monthly $3,051.67
4 - Family Size 4, Income Annual $44,100, Monthly $3,675.00
5 - Family Size 5, Income Annual $51,576, Monthly $4,298.33
6 - Family Size 6, Income Annual $59,064, Monthly $4,921.67
7 - Family Size 7, Income Annual $66,450, Monthly $5,545.00
8 - Family Size 8, Income Annual $74,016 Monthly $6,168.33

Employment Status
Employed within last 6 months
Single Parent
Full Time Student

Unisured and not eligible for government assisted healthcare programs (such as Medicaid amd Medicare)
yes
no

Appointments

Your immunization appointment will be confirmed via email.

I AGREE

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Back to School BashImmunization Pre-Registration

Appointments

Back to School Bash
Immunization Pre-Registration