Florence Aldridge Center/Head Start Physical & Immunization Clinic

Rock Island Academy Physical & Immunization Clinic

Monday, October 20th, 2025, & Tuesday, October 21st, 2025, 9:00 AM -2:30 PM
***Please note that the clinic may be subject to cancellation if we do not have enough participants registered in advance.***
Appointment*
Parent/Guardian Name*

First NameLast Name
E-mail*
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Contact Number:*

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Taking any medications, currently?*

YesNo
Please list medications
Are you interested in enrolling in MyChart patient portal?*

YesNoAlready Enrolled
Should be Empty:

Rock Island Academy Physical & Immunization Clinic