Baltimore County Department of Health Mobile Vaccine Event Pre-Registration Form

Baltimore County Department of Health Mobile Vaccine Event Pre-Registration Form

Back to School 2025
Baltimore County Department of Health is offering several mobile vaccine clinics to help students and families get their school-required vaccines before the school vaccine deadline of 9/12/25.

Please complete this form to pre-register for an event. Pre-registration is encouraged but not required.

Important information:
- Please review your child's vaccine needs closely and compare to what is offered at the event you select.
- If you cannot attend one of our mobile events, you are welcome to schedule a vaccine appointment at one of our health centers by calling 410-887-2705.
- Vaccines at mobile events are provided at no cost.
- You do not need to bring an ID or health insurance information.
- If your school nurse has sent you a letter or other communication about the vaccines your student needs, please bring that with you to the clinic. If not, please bring any other vaccine records you have available for your student.
Student's Information
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Date
Gender*

FemaleMaleOtherDecline to Specify
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteOtherUnknown / Not ReportedDecline to specify
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown / not reported
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Event Selection
Choose Event Date and Location*

Monday, 8/11/25 from 5-7pm at Pikesville Middle School (all vaccines)Wednesday, 8/13/25 from 4-7pm at Deer Park Middle Magnet (MCV and Tdap only)Saturday, 8/16/25 from 11am-1pm at New Town High School (all vaccines)Tuesday, 8/26/25 from 4-6pm at Cockeysville Middle School (MCV and Tdap only)Thursday, 8/28/25 from 4-6pm at Holabird Middle School (MCV and Tdap only)Tuesday, 9/2/25 from 4-6pm at Nottingham Middle School (MCV and Tdap only)Wednesday, 9/3/25 from 4-6pm at Lansdowne Middle School (MCV and Tdap only)Wednesday, 9/10/25 from 4-6pm at Southwest Academy (MCV and Tdap only)Thursday, 9/11/25 from 4-6pm at Sudbrook Middle School (MCV and Tdap only)
Parent or Guardian Contact Information
Parent or Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Will you need interpretation services?*

YesNo
What is your preferred language?*
Consent*

I confirm that the information on this form is accurate, and I consent to the information I have submitted to be shared with the CDC Vaccine Administration Management System (VAMS). More information on VAMS can be found at vams.cdc.gov.
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Baltimore County Department of Health Mobile Vaccine Event Pre-Registration Form

Student's Information

Event Selection

Parent or Guardian Contact Information