COVID-19 VACCINE/BOOSTER REGISTRATION FORM

Name *

First

Last

Phone Number (only numbers. no dash, dot or slash) *

Email *

Age *

Which Company Vaccine/Booster shot do you want? *

Pfizer
Moderna

Is this your 1st, 2nd or Booster shot? Please enter below. *

If Vaccinated then please enter Date and Time of vaccination. *

Any Comments?

Please bring CDC issue vaccine card so we can confirm 5 months required timeframe after the second shot. Also, request the community to bring ids, such as driving license, birth certificate or passport.