Hindu Temple of KC / Appointments for Covid Vaccination
Email (Must have for appointment confirmation)
Email address *
Please read carefully
Filling this form to request an appointment is not a guarantee you will get one. We will only forward information to Medical facility and they will reach out to you if a slot is available based on criteria.

Only one request per person. Multiple requests for the same person will be rejected.
If you had already submitted a request, no need for another one.
If you want to update details submitted, check your acknowledgement email for steps.
First Name *
Last Name *
Date of Birth (Must be 65 or older) *
If you are below 65 years, your information will not be processed.
Street address *
City *
State *
Phone number *
Gender *
Appointment session *
A copy of your responses will be emailed to the address you provided.
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