Back to School Vaccine Registration Form
Bethany Community Ministries is hosting a COVID-19 Vaccination Clinic in East Hills in partnership with the Brothers of Phi Beta Sigma Fraternity, Inc. and the PA Department of Health. Please complete this form to pre-register for the event. Children under 18 must be accompanied by an adult to receive the vaccine.

Kids get a $30 Foot Locker gift card, a bookbag, and priority slotting for a free haircut when they get a vaccine!

Vaccines Available:
- Pfizer (2-step)
- Moderna (2-step)

Date: Saturday, August 20, 2022
Location: 2291 Wilner Drive
Pittsburgh, PA 15221
Time: 11:00 am to 3:00 pm
Cost: FREE!
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First Name *
Last Name *
Phone Number *
Phone Type *
Email Address *
Zip Code *
Date of Birth *
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Race *
Required
Ethnicity *
Gender *
Who is your insurance provider? *
Which vaccine do you want to receive? *
Which dose will you be receiving? *
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