Vaccine Registration Who is receiving the vaccine? * First Name Last Name Email * Birth date * (Vaccine recipient's birth date that appears on their ID) MM DD YYYY City / Town Zip Code * (enter your legal residence, that matches your ID) Phone * (###) ### #### Will you need a ride to the vaccination site? * Yes Maybe (not sure yet) No Do you need interpreting services? * If you are limited in your understanding of English, we can have interpreters at the vaccination sites, to assist with the check-in documents during your appointment. Yes No Message * Please state any scheduling restrictions, for appointments. Thank you!
