Feedback Form/Shabbos Food Package Registration for Holocaust Survivors
Are you providing feedback for a Holocaust Survivor who received the COVID-19 vaccination? *
Holocaust survivor's first name - (legal) *
Holocaust survivor's last name *
Address *
Please share your COVID-19 vaccination experience. (Write n/a if you have not yet received your vaccination.) *
Phone number *
Date of birth - month/day/year *
Email address *
Primary contact- family or caretaker *
Phone number of primary contact *
Did you get the COVID-19 vaccination facilitated through the BPJCC/Boro Park Y/Ezra Medical Center program? *
Did you receive the first COVID-19 vaccination? *
Did you receive the second COVID-19 vaccination? *
Did you receive transportation from us when you got your vaccination? *
Please share any feedback you might have regarding the transportation service provided. (Write n/a if you did not request transportation.) *
What is the name of your primary social service agency? *
Please share any additional comments you might have regarding the COVID-19 vaccination appointment process which we facilitated for you. Your feedback on how the process went will enable us to better the program going forward and will help us improve on our efforts in all that we do to assist Holocaust survivors throughout the year. *
Would you like to receive free Shabbos meals from the BPJCC, Boro Park Y, Ezra Medical Center program sponsored by our partners Blue Card and Heritage Levavot? These meals will be send out every other month for an entire year. Please be aware that registration is only for those Holocaust survivors who have been vaccinated. Registration does not guarantee you will receive the meals, due to is limited availability. *
Visit https://www.bpjcc.org/donate to make a donation and have a part in the BPJCC's many vital events and services.
Thank you, for your response. If you registered for the Rosh Chodesh Shabbos box food delivery, we will reach out to you if you are one of the first 50 applicants or if future funding becomes available for us to expand this service.
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