Requesting a COVID-19 vaccination for 5-11 year olds living with someone who is immunosuppressed in North Wales.

1. Introduction

Following extensive assessment of the risks and benefits of vaccinations for 5 to 11 year olds, the JCVI has updated its advice for this age group. Children aged 5 to 11 who are living with someone (of any age) who is immunosuppressed, should be offered a primary course of COVID-19 vaccination. If you are a parent or guardian of a child living in North Wales who fits into the above age group and criteria, please fill in the following form to request a COVID-19 vaccination for the child.

1. Full name of parent/ guardian requesting for the child to be vaccinated *


2. Parent/ Guardian's telephone number *


3. Full name of at least one person who is immunosuppressed and living in the same household as the child. *


4. Following on from the previous question - date of birth of the immunosuppressed person living with the child: *


5. Full name of the 5-11 year old child *


6. Date of birth of the 5-11 year old child *


7. Address of the 5-11 year old child *


8. Postcode of the 5-11 year old child *