COVID Vaccine Registration

Student Health Services will be offering first and second dose COVID vaccinations (Moderna) to Brock students who are 18 years or older. Vaccinations will be done at Student Health Services, Harrison Hall, Brock Campus.

To receive the vaccine, students must register using the form, below. Students will be contacted using their preferred contact method for an appointment when it is available.

If you have received your first dose, please indicate the date.

The student’s consent to receive the vaccine may be withdrawn or revoked at any time.

Any questions may be directed to:

  • Name * Required
  • Preferred Name (optional)
  • Date Format: MM slash DD slash YYYY
  • Sex Assigned at Birth * Required
    This information is used for the purpose of registering for the vaccine. Your responses will be kept private and secure.
  • How should we contact you? * Required
  • What vaccination do you require? * Required
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.