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.
Do you have a pediatrician?
Legal Resident of United States
Currently living in Orange County, FL
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
Employed within last 6 months
Full Time Student
Unisured and not eligible for government assisted healthcare programs (such as Medicaid amd Medicare)
Your immunization appointment will be confirmed via email.