District 47 – Flu Shot Registration Form ***This form works best with Google Chrome*** Company Name * Crystal Lake School District 47 Location * Bernotas Middle SchoolCORE CenterCoventry Elementary SchoolGlacier Ridge Elementary SchoolHannah Beardsley Middle SchoolSouth Elementary SchoolWest Elementary School Appointment Time * Monday Oct. 2nd - 6:30 AM - 7:30 AM Monday Oct. 2nd - 2:15 PM - 3:30 PM Appointment Time * Tuesday Oct. 3rd - 7:00 AM - 8:30 AM Tuesday Oct. 3rd - 3:30 PM - 4:30 PM Appointment Time * Wednesday Oct. 4th - 7:00 AM - 8:30 AM Wednesday Oct. 4th - 3:30 PM - 4:30 PM Appointment Time * Thursday Oct. 5th - 7:00 AM - 8:30 AM Thursday Oct. 5th - 3:30 PM - 4:30 PM Appointment Time * Friday Oct. 6th - 7:00 AM - 8:30 AM Friday Oct. 6th - 3:30 PM - 4:30 PM Appointment Time * Tuesday Oct. 10th - 6:30 AM - 7:30 AM Tuesday Oct. 10th - 2:15 PM - 3:30 PM Appointment Time * Thursday Oct. 12th - 7:00 AM - 9:00 AM Thursday Oct. 12th - 3:00 PM - 4:00 PM Name * Legal First Last * Legal Last Status * Employee Family Member Do you have Blue Cross Blue Shield PPO? * Yes No - $45 Your insurance status will be validated. Family member status * SpouseDependent (18 and over) Group Number * ID Number * Primary Insured Name * Street address * City * State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip * Daytime phone# * Alternate phone# Birth date * Age Sex * Male Female Other Email Address * Total charges Total charges: $ Captcha If you are human, leave this field blank.
