Bay Mills Covid-19 Clinic April 8, 2021
This vaccination clinic will be held by Bay Mills Health Center at the Armella Parker Elder Building in Bay Mills Indian Community from 1pm until 4pm. Please complete this form, and you will receive a confirmation email the day before. If you have any questions, please feel free to call (906)248-8368 and leave a message with your name, phone number, and question so that you can be called back.
This vaccination clinic is using the Moderna Vaccine, which is approved for people 18 and older. More information about the Moderna Vaccine can be found here:
https://www.fda.gov/media/144638/download
* Required
Email address
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Your email
First Name
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Your answer
Last Name
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Your answer
What is your Date of Birth?
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**As this is a Moderna vaccination, you MUST be 18 or older to be able to receive this vaccine. If you register and are younger than 18, your response will be deleted.
Your answer
Gender
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Female
Male
Decline to say
Other:
Race
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American Indian/Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White/Caucasian
Prefer not to say/Unknown
Other:
Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Prefer not to say/Unknown
Address Line 1:
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Your answer
Address Line 2:
Your answer
City
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Your answer
State
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Your answer
Zip Code
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Your answer
Phone Number
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Your answer
We are not able to offer you a vaccination if you have recently been told you need to isolate or quarantine because you've had a direct exposure to someone with Covid-19.
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If you have been recently exposed, and told you need to isolate, we will not be able to offer you a vaccination appointment at this time. You would risk potentially exposing one of our staff or volunteers. If you have been told that you need to isolate, you will eligible for a vaccination at one of our future vaccine clinics.
For the safety of the staff and volunteers of Bay Mills Health Center, I acknowledge that I have NOT been told within the last 7 days that I need to isolate or quarantine due to a direct Covid-19 exposure.
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A copy of your responses will be emailed to the address you provided.
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